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Global Strategy for

Asthma Management and Prevention
Updated 2023

© 2023 Global Initiative for Asthma

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Global Strategy for Asthma Management and Prevention

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(2023 update)

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The reader acknowledges that this report is intended as an evidence-based asthma management strategy, for
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the use of health professionals and policy-makers. It is based, to the best of our knowledge, on current best
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evidence and medical knowledge and practice at the date of publication. When assessing and treating patients,
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health professionals are strongly advised to use their own professional judgment, and to take into account local
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and national regulations and guidelines. GINA cannot be held liable or responsible for inappropriate healthcare
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associated with the use of this document, including any use which is not in accordance with applicable local or
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national regulations or guidelines.

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Suggested citation: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2023.
Updated July 2023. Available from: www.ginasthma.org

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Table of contents
Tables and figures ............................................................................................................................................................. 5
Preface ................................................................................................................................................................................ 7
Members of GINA committees (2022–23) ........................................................................................................................ 8
Abbreviations ................................................................................................................................................................... 10
Methodology ..................................................................................................................................................................... 13
What’s new in GINA 2023? .............................................................................................................................................. 17
SECTION 1. ADULTS, ADOLESCENTS AND CHILDREN 6 YEARS AND OLDER ...........................................................21
Chapter 1. Definition, description, and diagnosis of asthma .................................................................................... 21
Definition of asthma ................................................................................................................................................... 22

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Description of asthma ................................................................................................................................................ 22

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Making the initial diagnosis ........................................................................................................................................ 23

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Confirming the diagnosis of asthma in patients already taking ICS-containing treatment ........................................29

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Differential diagnosis .................................................................................................................................................. 30

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How to make the diagnosis of asthma in other contexts ........................................................................................... 31
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Chapter 2. Assessment of asthma ................................................................................................................................ 33
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Overview .................................................................................................................................................................... 35
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Assessing asthma symptom control .......................................................................................................................... 36

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Assessing future risk of adverse outcomes ............................................................................................................... 40

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Role of lung function in assessing asthma control..................................................................................................... 41

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Assessing asthma severity ........................................................................................................................................ 42

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Chapter 3. Treating asthma to control symptoms and minimize risk ....................................................................... 47

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3.1. General principles of asthma management ............................................................................................................ 48

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Long-term goals of asthma management .................................................................................................................. 49

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The patient-health care provider partnership ............................................................................................................. 49

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Personalized control-based asthma management .................................................................................................... 50

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3.2. Medications and strategies for symptom control and risk reduction ....................................................................... 53
Asthma medications ................................................................................................................................................... 55
Asthma treatment steps for adults, adolescents and children 6–11 years ................................................................ 68
STEP 1 ....................................................................................................................................................................... 68
STEP 2 ....................................................................................................................................................................... 71
STEP 3 ....................................................................................................................................................................... 74
STEP 4 ....................................................................................................................................................................... 76
STEP 5 ....................................................................................................................................................................... 78
Reviewing response and adjusting treatment ............................................................................................................ 81
Other strategies for adjusting asthma treatment ........................................................................................................ 84

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 Treating other modifiable risk factors......................................................................................................................... 84
Other therapies .......................................................................................................................................................... 86
Non-pharmacological strategies ................................................................................................................................ 88
Indications for referral for expert advice .................................................................................................................... 97
3.3. Guided asthma self-management education and skills training ............................................................................. 98
Skills training for effective use of inhaler devices ...................................................................................................... 98
Shared decision-making for choice of inhaler device ................................................................................................ 98
Adherence with medications and with other advice ................................................................................................. 101
Asthma information .................................................................................................................................................. 102
Training in guided asthma self-management .......................................................................................................... 103
3.4. Managing asthma with multimorbidity and in specific populations ....................................................................... 106

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Managing multimorbidity .......................................................................................................................................... 106

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Managing asthma during the COVID-19 pandemic ................................................................................................. 109

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Managing asthma in specific populations or settings .............................................................................................. 112

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3.5. Difficult-to-treat and severe asthma in adults and adolescents ............................................................................ 120

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Definitions: uncontrolled, difficult-to-treat and severe asthma ................................................................................. 121
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Prevalence: how many people have severe asthma? ............................................................................................. 121
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Importance: the impact of severe asthma................................................................................................................ 122

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Investigate and manage difficult-to-treat asthma in adults and adolescents ........................................................... 127
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Assess and treat severe asthma phenotypes .......................................................................................................... 129

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Manage and monitor severe asthma treatment ....................................................................................................... 136

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Chapter 4. Management of worsening asthma and exacerbations ......................................................................... 139

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Overview .................................................................................................................................................................. 141

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Diagnosis of exacerbations ...................................................................................................................................... 142

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Self-management of exacerbations with a written asthma action plan ................................................................... 142

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Management of asthma exacerbations in primary care (adults, adolescents, chldren 6–11 years) ....................... 147
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Management of asthma exacerbations in the emergency department (adults, adolescents, children 6–11 years)150
Discharge planning and follow-up ............................................................................................................................ 156
Chapter 5. Diagnosis and initial treatment of adults with features of asthma, COPD or both ............................. 159
Objectives ................................................................................................................................................................ 161
Background to diagnosing asthma and/or COPD in adult patients ......................................................................... 161
Assessment and management of patients with chronic respiratory symptoms ....................................................... 162
Future research ........................................................................................................................................................ 167
SECTION 2. CHILDREN 5 YEARS AND YOUNGER ......................................................................................................... 169
Chapter 6. Diagnosis and management of asthma in children 5 years and younger........................................... 169
6.1. Diagnosis .............................................................................................................................................................. 170

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 Asthma and wheezing in young children ................................................................................................................. 170
Clinical diagnosis of asthma .................................................................................................................................... 171
Tests to assist in diagnosis ...................................................................................................................................... 173
Differential diagnosis ............................................................................................................................................... 175
6.2. Assessment and management ............................................................................................................................. 177
Goals of asthma management ................................................................................................................................. 177
Assessment of asthma ............................................................................................................................................ 177
Medications for symptom control and risk reduction ................................................................................................ 179
Asthma treatment steps for children aged 5 years and younger ............................................................................. 181
Reviewing response and adjusting treatment ......................................................................................................... 184
Choice of inhaler device .......................................................................................................................................... 184

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Asthma self-management education for carers of young children ......................................................................... 186

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6.3. Management of worsening asthma and exacerbations in children 5 years and younger ....................................187

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Diagnosis of exacerbations ...................................................................................................................................... 187

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Initial home management of asthma exacerbations ................................................................................................ 188

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Primary care or hospital management of acute asthma exacerbations in children 5 years or younger ..................190
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Chapter 7. Primary prevention of asthma in children ............................................................................................... 195
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Factors contributing to the development of asthma in children ............................................................................... 196

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Factors associated with increased or decreased risk of asthma in children............................................................ 196

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Advice about primary prevention of asthma ............................................................................................................ 199

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SECTION 3. TRANSLATION INTO CLINICAL PRACTICE ................................................................................................ 201

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Chapter 8. Implementing asthma management strategies into health systems ....................................................201

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Introduction .............................................................................................................................................................. 202

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Adapting and implementing asthma clinical practice guidelines .............................................................................. 202

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Barriers and facilitators ............................................................................................................................................ 204

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Examples of high impact implementation interventions ........................................................................................... 204

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Evaluation of the implementation process ............................................................................................................... 205

How can GINA help with implementation? .............................................................................................................. 205
REFERENCES .................................................................................................................................................................... 206

4
Tables and figures
DIAGNOSIS
Box 1-1. Diagnostic flowchart for clinical practice 24
Box 1-2. Diagnostic criteria for asthma in adults, adolescents, and children 6–11 years 25
Box 1-3. Steps for confirming the diagnosis of asthma in a patient already taking ICS-containing treatment 28
Box 1-4. How to step down ICS-containing treatment to help confirm the diagnosis of asthma 29
Box 1-5. Differential diagnosis of asthma in adults, adolescents and children 6–11 years 30
ASSESSMENT
Box 2-1. Assessment of asthma in adults, adolescents, and children 6–11 years 35
Box 2-2. GINA assessment of asthma control in adults, adolescents and children 6–11 years 38
Box 2-3. Specific questions for assessment of asthma in children 6–11 years 39
Box 2-4. Investigating a patient with poor symptom control and/or exacerbations despite treatment 45

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ASTHMA MANAGEMENT

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Box 3-1. Communication strategies for health care providers 49

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Box 3-2. The asthma management cycle for personalized asthma care 50

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Box 3-3. Population level versus patient level decisions about asthma treatment 52

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Box 3-4. Terminology for asthma medications 56

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Box 3-5. Asthma treatment tracks for adults and adolescents 58

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Initial treatment choices O
Box 3-6. Initial asthma treatment - recommended options for adults and adolescents 59
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Box 3-7. Selecting initial treatment in adults and adolescents with a diagnosis of asthma 60
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Box 3-8. Flowchart for selecting initial treatment in adults and adolescents with a diagnosis of asthma 61
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Box 3-9. Initial asthma treatment – recommended options for children aged 6–11 years 62
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Box 3-10. Selecting initial treatment in children aged 6–11 years with a diagnosis of asthma 63
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Box 3-11. Flowchart for selecting initial treatment in children aged 6–11 years with a diagnosis of asthma 64
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Main treatment figures

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Box 3-12. Personalized management for adults and adolescents to control symptoms and minimize future risk 65
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Box 3-13. Personalized management for children 6–11 years to control symptoms and minimize future risk 66
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Box 3-14. Low, medium and high daily metered doses of inhaled corticosteroids (alone or with LABA)
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Box 3-15. Medications and doses for GINA Track 1: anti-inflammatory reliever (AIR)-based therapy
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Ongoing management
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Box 3-16. Options for stepping down treatment in adults and adolescents once asthma is well controlled 83
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Box 3-17. Treating potentially modifiable risk factors to reduce exacerbations 85

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Box 3-18. Non-pharmacological interventions – summary 88

Box 3-19. Effectiveness of avoidance measures for indoor allergens 93
Box 3-20. Indications for considering referral for expert advice, where available 97
Box 3-21. Shared decision-making between health professional and patient about choice of inhalers 99
Box 3-22. Choice and effective use of inhaler devices 100
Box 3-23. Poor adherence with prescribed maintenance treatment in asthma 102
Box 3-24. Asthma information 103
Difficult-to-treat and severe asthma
Box 3-25. What proportion of adults have difficult-to-treat or severe asthma? 121
Box 3-26. Decision tree – investigate and manage difficult to treat asthma in adult and adolescent patients 123
Box 3-27. Decision tree – assess and treat severe asthma phenotypes 124
Box 3-28. Decision tree – consider add-on biologic Type 2-targeted treatments 125
Box 3-29. Decision tree – monitor and manage severe asthma treatment 126

5
EXACERBATIONS
Box 4-1. Factors that increase the risk of asthma-related death 141
Box 4-2. Self-management of worsening asthma in adults and adolescents with a written asthma action plan 146
Box 4-3. Management of asthma exacerbations in primary care (adults, adolescents, children 6–11 years) 148
Box 4-4. Management of asthma exacerbations in acute care facility, e.g. emergency department 152
Box 4-5. Discharge management after hospital or emergency department care for asthma 157
ASTHMA, COPD AND ASTHMA+COPD
Box 5-1. Current definitions of asthma and COPD, and clinical description of asthma-COPD overlap 162
Box 5-2. Approach to initial treatment in patients with asthma and/or COPD 163
Box 5-3. Spirometric measures in asthma and COPD 164
Box 5-4. Specialized investigations sometimes used in patients with features of asthma and COPD 166
CHILDREN 5 YEARS AND YOUNGER
Box 6-1. Probability of asthma diagnosis in children 5 years and younger 171

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Box 6-2. Features suggesting a diagnosis of asthma in children 5 years and younger 172

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Box 6-3. Questions that can be used to elicit features suggestive of asthma 173

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Box 6-4. Common differential diagnoses of asthma in children 5 years and younger 175

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Box 6-5. GINA assessment of asthma control in children 5 years and younger 178

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Box 6-6. Personalized management of asthma in children 5 years and younger 183

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Box 6-7. Low daily doses of inhaled corticosteroids for children 5 years and younger 184

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Box 6-8. Choosing an inhaler device for children 5 years and younger 185
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Management of acute asthma or wheezing in children 5 years and younger 189
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Box 6-10. Initial assessment of acute asthma exacerbations in children 5 years and younger 190
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Box 6-11. Indications for immediate transfer to hospital for children 5 years and younger 191
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Box 6-12. Initial emergency department management of asthma exacerbations in children 5 years and younger 192
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PRIMARY PREVENTION OF ASTHMA IN CHILDREN

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Box 7-1. Advice about primary prevention of asthma in children 5 years and younger 199
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IMPLEMENTATION STRATEGIES
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Box 8-1. Approach to implementation of the Global Strategy for Asthma Management and Prevention 203
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Box 8-2. Essential elements required to implement a health-related strategy 203

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Box 8-3. Examples of barriers to the implementation of evidence-based recommendations 204

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Box 8-4. Examples of high-impact implementation interventions in asthma management 204

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Preface
Asthma is a serious global health problem affecting all age groups. Its prevalence is increasing in many countries,
especially among children. Although some countries have seen a decline in hospitalizations and deaths from asthma,
asthma still imposes an unacceptable burden on health care systems, and on society through loss of productivity in the
workplace and, especially for pediatric asthma, disruption to the family.

This year, the Global Initiative for Asthma celebrates 30 years of working to improve the lives of people with asthma by
translating medical evidence into better asthma care worldwide. Established in 1993 by the National Heart, Lung, and
Blood Institute and the World Health Organization, GINA works with healthcare professionals, researchers, patients and
public health officials around the world to reduce asthma prevalence, morbidity and mortality. The Global Strategy for
Asthma Management and Prevention (‘GINA Strategy Report’) was first published in 1995, and has been updated
annually since 2002 by the GINA Science Committee. It contains guidance for primary care practitioners, specialists and
allied health professionals, based on the latest high quality evidence available. More resources and supporting material

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are provided online at www.ginasthma.org.

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GINA supports global efforts to achieve environmental sustainability in health care, while ensuring that our guidance

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reflects an optimal balance between clinical and environmental priorities, with a particular focus on patient safety. GINA

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also supports efforts to ensure global availability of, and access to, effective quality-assured medications, to reduce the

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burden of asthma mortality and morbidity. Since 2001, GINA has organized the annual World Asthma Day, a focus for

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local and national activities to raise awareness of asthma and educate families and health care professionals about
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effective asthma care. In 2023, the theme for World Asthma Day is ‘Asthma Care for All’.
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GINA is an independent organization funded solely through sale and licensing of its educational publications. Members of
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the GINA Board of Directors are drawn globally from leaders with an outstanding demonstrated commitment to asthma
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research, asthma clinical management, public health and patient advocacy. GINA Science Committee members are highly
experienced asthma experts from around the world, who continually review and synthesize scientific evidence to provide
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guidance on asthma prevention, diagnosis and management. The GINA Dissemination Task Group is responsible for
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promoting GINA resources throughout the world. Members work with an international network of patient representatives
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and leaders in asthma care (GINA Advocates), to implement asthma education programs and support evidence-based
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care. GINA support staff comprise the Executive Director and Project Manager.
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We acknowledge the superlative work of all who have contributed to the success of the GINA program. In particular, we
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recognize the outstanding long-term dedication of founding Scientific Director Dr Suzanne Hurd and founding Executive
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Director Dr Claude Lenfant in fostering GINA’s development until their retirement in 2015. We acknowledge the invaluable
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commitment and skill of our current Executive Director Ms Rebecca Decker, BS, MSJ. We continue to recognize the
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contribution of Prof J Mark FitzGerald to GINA for over 25 years until his passing in 2022. We also thank all members of
the Science Committee, who receive no honoraria or reimbursement for their many hours of work in reviewing evidence
and attending meetings, and the GINA Dissemination Task Group and Advocates.

We hope you find this report to be a useful resource in the management of asthma and that it will help you work with each
of your patients to provide the best personalized care,

Helen K Reddel, MBBS PhD Arzu Yorgancıoğlu, MD

Chair, GINA Science Committee Chair, GINA Board of Directors

7
Members of GINA committees (2022–23)

GINA SCIENTIFIC COMMITTEE

Helen K. Reddel, MBBS PhD, Chair Francine Ducharme, MD
Woolcock Institute of Medical Research, Departments of Pediatrics and of Social and Preventive
Macquarie University Medicine, Sainte-Justine University Health Centre,
Sydney, Australia University of Montreal
Montreal, Quebec, Canada
Leonard B. Bacharier, MD
Vanderbilt University Medical Center Liesbeth Duijts, MD MSc Phd
Nashville, TN, USA University Medical Center
Rotterdam, The Netherlands
Eric D. Bateman, MD

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University of Cape Town Lung Institute Louise Fleming, MBChB MD

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Cape Town, South Africa Royal Brompton Hospital

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London, United Kingdom

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Matteo Bonini MD, PhD

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Department of Cardiovascular and Thoracic Sciences, Hiromasa Inoue, MD

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Università Cattolica del Sacro Cuore Kagoshima University

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Rome, Italy Kagoshima, Japan

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National Heart and Lung Institute (NHLI), Imperial College
Fanny Wai-san Ko, MD
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London, UK
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The Chinese University of Hong Kong
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Louis-Philippe Boulet, MD Hong Kong

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Université Laval
Refiloe Masekela MBBCh, PhD
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Québec, QC, Canada

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Department of Paediatrics and Child Health, University of

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Arnaud Bourdin, MD, PhD KwaZulu Natal

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Department of Respiratory Diseases, University of Durban, South Africa

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Montpellier
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Kevin Mortimer, BA/MA, MB/BChir, PhD

Montpellier, France
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Liverpool School of Tropical Medicine

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Christopher Brightling, FMedSci, PhD Liverpool, UK

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Leicester NIHR Biomedical Research Centre, Department of Paediatrics and Child Health, College of
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University of Leicester Health Sciences, School of Clinical Medicine, University of

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Leicester, UK KwaZulu-Natal, Durban, South Africa

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Guy Brusselle, MD, PhD Paulo Pitrez, MD, PhD

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Ghent University Hospital Hospital Moinhos de Vento

Ghent, Belgium Porto Alegre, Brazil
Roland Buhl, MD PhD Sundeep Salvi MD, PhD
Mainz University Hospital Pulmocare Research and Education (PURE) Foundation
Mainz, Germany Pune, India
Jeffrey M. Drazen, MD Aziz Sheikh, BSc, MBBS, MSc, MD
Brigham and Woman’s Hospital The University of Edinburgh
Boston, MA, USA Edinburgh, United Kingdom

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GINA BOARD OF DIRECTORS GINA DISSEMINATION TASK GROUP
Arzu Yorgancioglu, MD Chair Mark L. Levy, MD (Chair)
Celal Bayar University Locum GP
Department of Pulmonology London, UK
Manisa, Turkey
Keith Allan, CBiol, MRSB
Keith Allan, CBiol, MRSB Patient Partner
Patient Partner University Hospitals of Leicester
University Hospitals of Leicester Leicester, UK
Leicester, UK
Hiromasa Inoue, MD
Eric D. Bateman, MD Kagoshima University
University of Cape Town Lung Institute Kagoshima, Japan
Cape Town, South Africa
Helen K. Reddel, MBBS PhD, Chair

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Guy Brusselle, MD, PhD Woolcock Institute of Medical Research,

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Ghent University Hospital Macquarie University

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Ghent, Belgium Sydney, Australia

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Muhwa Jeremiah Chakaya, MD Arzu Yorgancioglu, MD

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Respiratory Society of Kenya Celal Bayar University

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Department of Medicine, Therapeutics, Dermatology and Department of Pulmonology

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Psychiatry, Kenyatta University Manisa, Turkey
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Nairobi, Kenya
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GINA PROGRAM
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Alvaro A. Cruz, MD
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Federal University of Bahia Rebecca Decker, BS, MSJ

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Salvador, BA, Brazil

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Kristi Rurey, AS
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Hiromasa Inoue, MD
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Kagoshima University EDITORIAL ASSISTANCE

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Kagoshima, Japan
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Charu Grover, PhD

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Jerry A. Krishnan, MD PhD

Jenni Harman, BVSc, BA
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University of Illinois Hospital & Health Sciences System

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Chicago, IL, USA

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GRAPHICS ASSISTANCE
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Mark L. Levy, MD
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Kate Chisnall
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Locum GP
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London, UK
INFORMATION DESIGN
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Helen K. Reddel, MBBS PhD

Tomoko Ichikawa, MS
Woolcock Institute of Medical Research,
Macquarie University Hugh Musick, MBA
Sydney, Australia Institute for Healthcare Delivery Design
University of Illinois, Chicago, USA

Disclosures for members of GINA committees can be found at www.ginasthma.org

9
Abbreviations
ABPA Allergic bronchopulmonary aspergillosis
ACE Angiotensin-converting enzyme
ACQ Asthma Control Questionnaire
ACT Asthma Control Test (see also cACT)
AERD Aspirin-exacerbated respiratory disease
AIR Anti-inflammatory reliever (see Box 3-4, p.56)
ANCA Antineutrophil cytoplasmic antibody
Anti-IL4Rα Anti-interleukin 4 receptor alpha (monoclonal antibody)
Anti-IL5 Anti-interleukin 5 (monoclonal antibody)

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Anti-IL5R Anti-interleukin 5 receptor (monoclonal antibody)

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Anti-TSLP Anti-thymic stromal lymphopoietin (monoclonal antibody)

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APGAR Activities, Persistent, triGgers, Asthma medications, Response to therapy

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ATS/ERS American Thoracic Society and European Respiratory Society

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BDP Beclometasone dipropionate

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BD Bronchodilator O
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BMI Body mass index
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BNP B-type natriuretic peptide

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bpm Beats per minute

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BTS British Thoracic Society

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cACT Childhood Asthma Control Test

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CBC Complete blood count (also known as full blood count [FBC])
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CDC Centers for Disease Control and Prevention [USA]

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CI Confidence interval
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COPD Chronic obstructive pulmonary disease

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COVID-19 Coronavirus disease 2019

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CRP C-reactive protein

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CRSwNP Chronic rhinosinusitis with nasal polyps

CRSsNP Chronic rhinosinusitis without nasal polyps
CT Computerized tomography
CXR Chest X-ray
DLCO Diffusing capacity in the lung for carbon monoxide
DEXA Dual-energy X-ray absorptiometry
DPI Dry-powder inhaler
ED Emergency department
EGPA Eosinophilic granulomatosis with polyangiitis
FeNO Fractional concentration of exhaled nitric oxide
FEV1 Forced expiratory volume in 1 second (measured by spirometry)

10 Abbreviations
 FVC Forced vital capacity (measured by spirometry)
FEV1/FVC Ratio of forced expiratory volume in 1 second to forced vital capacity
GERD Gastro-esophageal reflux disease (GORD in some countries)
GOLD Global Initiative for Chronic Obstructive Pulmonary Disease
GRADE Grading of Recommendations Assessment, Development and Evaluation (an approach to clinical
practice guideline development)
HDM House dust mite
HEPA High-efficiency particulate air
HFA Hydrofluoroalkane propellant
HIV/AIDS Human immunodeficiency virus/acquired immunodeficiency syndrome
ICS Inhaled corticosteroid

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Ig Immunoglobulin

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IL Interleukin

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IM Intramuscular

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ICU Intensive care unit

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IV Intravenous
LABA Long-acting-beta2 agonist
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LAMA Long-acting muscarinic antagonist (also called long-acting anticholinergic)
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LMIC Low- and middle-income countries

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LTRA Leukotriene receptor antagonist (also called leukotriene modifier)

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MART Maintenance-and-reliever therapy (with ICS-formoterol); in some countries called SMART (single-
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inhaler maintenance-and-reliever therapy)

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n.a Not applicable

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NSAID Nonsteroidal anti-inflammatory drug

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NO2 Nitrogen dioxide (air pollutant)

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O2 Oxygen
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OCS Oral corticosteroids

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OSA Obstructive sleep apnea

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PaCO2 Arterial partial pressure of carbon dioxide

PaO2 Arterial partial pressure of oxygen
PEF Peak expiratory flow
PM10 Particulate matter with a particle diameter of 10 micrometers or less (air pollution)
pMDI Pressurized metered-dose inhaler
QTc Corrected QT interval on electrocardiogram
RCT Randomized controlled trial
SABA Short-acting beta2 agonist
SC Subcutaneous
SCIT Subcutaneous allergen immunotherapy

Abbreviations 11
sIgE Specific immunoglobulin E
SLIT Sublingual immunotherapy
S02 Sulfur dioxide (air pollutant)
T2 Type 2 airway inflammation (an asthma phenotype)
TSLP Thymic stromal lymphopoietin
URTI Upper respiratory tract infection
VCD Vocal cord dysfunction (included in inducible laryngeal obstruction)
WHO World Health Organization
WHO-PEN The World Health Organization Package of Essential Noncommunicable disease interventions for
primary care

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12 Abbreviations
Methodology
GINA SCIENCE COMMITTEE
The GINA Science Committee was established in 2002 to review published research on asthma management and
prevention, to evaluate the impact of this research on recommendations in GINA documents, and to provide yearly
updates to these documents. The members are recognized leaders in asthma research and clinical practice, with the
scientific expertise to contribute to the task of the Committee. They are invited to serve for a limited period and in a
voluntary capacity. The Committee is broadly representative of adult and pediatric disciplines, and members are drawn
from diverse geographic regions. The Science Committee normally meets twice yearly, in conjunction with the American
Thoracic Society (ATS) and European Respiratory Society (ERS) international conferences, to review asthma-related
scientific literature. During COVID-19, meetings of the Science Committee were held online each month. Statements of
interest for Committee members are found on the GINA website www.ginasthma.org.

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PROCESSES FOR UPDATES AND REVISIONS OF THE GINA STRATEGY REPORT

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Literature search

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Details are provided on the GINA website (www.ginasthma.org/about-us/methodology). In summary, two PubMed

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searches are performed each year, each covering the previous 18 months, using filters established by the Science

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Committee. The search terms include asthma, all ages, only items with abstracts, clinical trial or meta-analysis or

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systematic review, and human. The search is not limited to specific PICOT (Population, Intervention, Comparison,
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Outcomes, Time) questions. The ‘clinical trial’ publication type includes not only conventional randomized controlled
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trials, but also pragmatic, real-life and observational studies. The search for systematic reviews includes, but is not
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limited to, those conducted using GRADE methodology.1 An additional search is conducted for guidelines documents
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published by other international organizations. The respiratory community is also invited to submit any other fully
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published peer-reviewed publications for consideration, providing that the full paper is submitted in (or translated into)
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English; however, because of the comprehensive process for literature review, such ad hoc submissions have rarely
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resulted in substantial changes to the report.

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Systematic reviews
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Unique among evidence-based recommendations in asthma, and most other therapeutic areas, GINA conducts an
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ongoing twice-yearly update of the evidence base for its recommendations. GINA does not carry out or commission its
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own GRADE-based reviews, because of the current cost of such reviews, the large number of PICOT questions that
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would be necessary for a comprehensive practical report of this scope, and because it would limit the responsiveness of
R

the GINA Strategy Report to emerging evidence and new developments in asthma management. However, the Science
PY

Committee reviews relevant systematic reviews conducted with GRADE methodology as part of its normal review
O
C

process, once such reviews are published. GINA recommendations are constantly being reviewed and considered for
update as new evidence (including GRADE-based systematic reviews on specific topics) is identified and indicates the
need.
Literature screening and review
Each article identified by the literature search, after removal of duplicates and those already reviewed, is pre-screened in
Covidence for relevance and major quality issues by the Editorial Assistant and by at least two non-conflicted members
of the Science Committee. Each publication selected from screening is reviewed for quality and relevance by at least
two members of the Science Committee, neither of whom may be an author (or co-author) or declare a conflict of
interest in relation to the publication. Articles that have been accepted for publication and are online in advance of print
are eligible for full text review if the approved/corrected copy-edited proof is available. All members receive a copy of all
abstracts and full text publications, and non-conflicted members have the opportunity to provide comments during the
pre-meeting review period. Members evaluate the abstract and the full text publication, and answer written questions in
a review template about whether the scientific data impact on GINA recommendations, and if so, what specific changes

Methodology 13
 should be made. In 2020, the Critical Appraisal Skills Programme (CASP) checklist2 was provided in the review template
to assist in evaluation of systematic reviews. A list of all publications reviewed by the Committee is posted on the GINA
website (www.ginasthma.org).
Discussion and decisions during Science Committee meetings
Each publication that is assessed by at least one reviewer to potentially impact on the GINA Strategy Report is
discussed in a Science Committee meeting (virtual or face-to-face). This process comprises three parts, as follows:
1. Quality and relevance of original research and systematic review publications. First, the Committee considers the
relevance of the publication to the GINA Strategy Report, the quality of the study, the reliability of the findings, and the
interpretation of the results, based on the responses from reviewers and discussion by members of the Committee. For
systematic reviews, GRADE assessments, if available, are taken into account. However, for any systematic review,
GINA members also independently consider the clinical relevance of the question addressed by the review, and the
scientific and clinical validity of the included populations and study design. During this discussion, a member who is an
author (or was involved in the study) may be requested to provide clarification or respond to questions about the study,

TE
but they may not otherwise take part in this discussion about the quality and relevance of the publication.

U
IB
2. Decision about inclusion of the evidence. During this phase, the Committee decides whether the publication or its

TR
findings affect GINA recommendations or statements and should be included in the GINA Strategy Report. These

IS
decisions to modify the report or its references are made by consensus by Committee members present and, again, any

D
R
member with a conflict of interest is excluded from these decisions. If the chair is an author on a publication being

O
reviewed, an alternative chair is appointed to lead the discussion in part 1 and the decision in part 2 for that publication.
PY
O
3. Discussion about related changes to the GINA Strategy Report. If the committee resolves to include the publication or
C

its findings in the report, an author or conflicted member, if present, is permitted to take part in the subsequent
T
O

discussions about and decisions on changes to the report, including the positioning of the study findings in the report
N

and the way that they would be integrated with existing (or other new) components of the GINA management strategy.
O
-D

These discussions may take place immediately, or over the course of the year as new evidence emerges or as other
L

changes to the report are agreed and implemented. The approach to managing conflicts of interest, as described above,
IA

also applies to members of the GINA Board who ex-officio attend GINA Science Committee meetings.
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AT

As with all previous GINA Strategy Reports, levels of evidence are assigned to management recommendations where
M

appropriate. Current criteria (Table A; p.15) are based on those originally developed by the National Heart Lung and
D

Blood Institute. From 2019, GINA has included in ‘Level A’ strong observational evidence that provides a consistent
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pattern of findings in the population for which the recommendation is made, and has also described the values and
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preferences that were taken into account in making major new recommendations. The table was updated in 2021 to
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avoid ambiguity about the positioning of observational data and systematic reviews.
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New therapies and indications

C

The GINA Strategy Report is a global strategy document. Since regulatory approvals differ from country to country, and
manufacturers do not necessarily make regulatory submissions in all countries, some GINA recommendations are likely
to be off-label in some countries. This is a particular issue for pediatrics, where across different diseases, many
treatment recommendations for pre-school children and for children aged 6–11 years are off-label.
For new therapies, GINA’s aim is to provide clinicians with evidence-based guidance about new therapies and their
positioning in the overall asthma treatment strategy as soon as possible; otherwise the gap between regulatory approval
and the periodic update of many national guidelines is filled only by advertising or educational material produced by the
manufacturer or distributor. For new therapies for which the GINA Science Committee considers there is sufficient good-
quality evidence for safety and efficacy or effectiveness in relevant asthma populations, recommendations may be held
until after approval for asthma by at least one major regulatory agency (e.g. European Medicines Agency or US Food
and Drug Administration), since regulators often receive substantially more safety and/or efficacy data on new
medications than are available to GINA through peer-reviewed literature. However, decisions by GINA to make or not
make a recommendation about any therapy, or about its use in any specific population, are based on the best available

14 Methodology
 peer-reviewed evidence and not on labeling directives from regulators.
For existing therapies with evidence for new regimens or in different populations, the Science Committee may, where
relevant, make recommendations that are not necessarily covered by regulatory indications in any country at the time,
provided the Committee is satisfied with the available evidence around safety and efficacy/effectiveness. Since the
GINA Strategy Report represents a global strategy, the report does not refer to recommendations being ‘off-label’.
However, readers are advised that, when assessing and treating patients, they should use their own professional
judgment and should also take into account local and national guidelines and eligibility criteria, as well as locally
licensed drug doses.
External review
Prior to publication each year, the GINA Strategy Report undergoes extensive external review by patient advocates and
by asthma care experts from primary and specialist care in multiple countries. There is also continuous external review
throughout the year in the form of feedback from end-users and stakeholders through the contact form on the GINA
website.

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Table A. Description of levels of evidence used in this report

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Evidence Sources

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Definition

D
level of evidence

R
O
A Randomized controlled Evidence is from endpoints of well-designed RCTs, systematic reviews of relevant
trials (RCTs), systematic PY
studies or observational studies that provide a consistent pattern of findings in the
O
C
reviews, observational population for which the recommendation is made. Category A requires substantial
T

evidence. Rich body of numbers of studies involving substantial numbers of participants.

O
N

data.
O
-D

B Randomized controlled Evidence is from endpoints of intervention studies that include only a limited
L

trials and systematic number of patients, post hoc or subgroup analysis of RCTs or systematic reviews
IA

reviews. Limited body of of such RCTs. In general, Category B applies when few randomized trials exist,
ER

data. they are small in size, they were undertaken in a population that differs from the
AT

target population of the recommendation, or the results are somewhat inconsistent.

M
D

C Nonrandomized trials or Evidence is from non-randomized trials or observational studies.

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observational studies.
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IG

D Panel consensus This category is used only in cases where the provision of some guidance was
R
PY

judgment. deemed valuable but the clinical literature addressing the subject was insufficient to
O

justify placement in one of the other categories. The Panel Consensus is based on
C

clinical experience or knowledge that does not meet the above listed criteria.

LITERATURE REVIEWED FOR GINA 2023 UPDATE

The GINA Strategy Report has been updated in 2023 following the routine twice-yearly review of the literature by the
GINA Science Committee. The literature searches for ‘clinical trial’ publication types (see above), systematic reviews and
guidelines identified a total of 3698 publications, of which 3118 duplicates/animal studies/non-asthma/pilot studies and
protocols were removed. A total of 580 publications underwent screening of title and abstract by at least two reviewers,
and 491 were screened out for relevance and/or quality. A total of 89 publications underwent full-text review by at least
two members of the Science Committee, and 52 publications were subsequently discussed at meetings of the Science
Committee. A list of key changes in GINA 2023 can be found starting on p.17, and a tracked changes copy is archived on
the GINA website at www.ginasthma.org/archived-reports/.

Methodology 15
FUTURE CHALLENGES
Despite laudable efforts to improve asthma care over the past 30 years, and the availability of effective medications,
many patients globally have not benefited from advances in asthma treatment and often lack even the rudiments of care.
Many of the world’s population live in areas with inadequate medical facilities and meager financial resources. GINA
recognizes that the recommendations found in this report must be adapted to fit local practices and the availability of
healthcare resources. To improve asthma care and patient outcomes, evidence-based recommendations must also be
disseminated and implemented nationally and locally, and integrated into health systems and clinical practice.
Implementation requires an evidence-based strategy involving professional groups and stakeholders and considering
local cultural and socioeconomic conditions. GINA is a partner organization in the Global Alliance against Chronic
Respiratory Diseases (GARD). Through the work of GINA, and in cooperation with GARD and the International Union
Against Tuberculosis and Lung Diseases (IUATLD), substantial progress toward better care for all patients with asthma
should be achieved in the next decade.
At the most fundamental level, patients in many areas do not have access to any inhaled corticosteroid-containing

TE
medications, which are the cornerstone of care for asthma patients of all severity. More broadly, medications remain the

U
major contributor to the overall costs of asthma management, so the access to and pricing of high quality asthma

IB
medications continues to be an issue of urgent need and a growing area of research interest.3-5 The safest and most

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effective approach to asthma treatment in adolescents and adults, which also avoids the consequences of starting

IS
D
treatment with SABA alone, depends on access to ICS–formoterol across all asthma severity levels.6,7 Budesonide-

R
formoterol is included in the World Health Organization (WHO) essential medicines list, so the fundamental changes to

O
treatment of mild asthma first included in the 2019 GINA Strategy Report may provide a feasible solution to reduce the
risk of severe exacerbations in low- and middle-income countries.7 PY
O
C

The urgent need to ensure access to affordable, quality-assured inhaled asthma medications as part of universal health
T
O

coverage must now be prioritized by all relevant stakeholders, particularly manufacturers of relevant inhalers. GINA is
N
O

collaborating with IUATLD and other organizations to work towards a World Health Assembly Resolution to improve
-D

equitable access to affordable care, including inhaled medicines, for children, adolescents and adults with asthma.5
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16 Methodology
What’s new in GINA 2023?
The GINA Strategy Report has been updated in 2023 following the routine twice-yearly cumulative review of the
literature by the GINA Scientific Committee. A copy showing tracked changes from the GINA 2022 report is archived on
the GINA website.
KEY CHANGES
• Clarification of terminology for asthma medications: a new table (Box 3-4, p.56) has been added to clarify
terminology for types of asthma medications, including the different meanings of ‘maintenance’ and ‘controller’
medications. The term ‘controller’ has been replaced where appropriate by ‘maintenance treatment’ or ‘ICS-containing
treatment’. The term anti-inflammatory reliever (‘AIR’), including as-needed ICS-formoterol and as-needed ICS-SABA,
reflects the dual purpose of these reliever inhalers. It is important to distinguish between as-needed use of an anti-
inflammatory reliever on its own (‘AIR-only’) in Steps 1–2, and maintenance and reliever therapy (‘MART’) with ICS-
formoterol in Steps 3–5. We suggest including these definitions in health professional education.

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• New commentary explaining the asthma management cycle: Commentary has been added to Box 3-2 (p.50) to

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assist clinicians to explain the asthma management cycle (assessment – adjustment – review) to patients, and to

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health professionals during education presentations. This figure is repeated in the GINA treatment figures for all age-

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groups, as a reminder about the key elements of asthma management.

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• Addition of as-needed ICS-SABA to GINA 2023 treatment figure for adults and adolescents: The figure (Box

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3-12, p.65) has been updated to include as-needed combination ICS-SABA (an anti-inflammatory reliever) in GINA
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Track 2. This addition was based on a clinical trial in patients taking GINA Steps 3–5 maintenance treatment, showing
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C
that using budesonide-salbutamol (budesonide-albuterol) as the reliever reduced the risk of severe exacerbations,
T
O

compared with a salbutamol (albuterol) reliever. Most of the benefit was seen in patients taking Step 3 treatment.
N

Additional details are found on p.74, p.76 and p.78. Only one small randomized controlled trial has examined as-
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needed-only ICS-SABA for Steps 1–2, and more studies are needed in children and adolescents. ICS-SABA is not
recommended for regular maintenance therapy, so it cannot be used for maintenance and reliever therapy.
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Despite the addition of ICS-SABA reliever in Track 2, GINA Track 1 with as-needed ICS-formoterol remains the
preferred treatment approach for adults and adolescents (Box 3-12, p.65). The reasons are: (a) the evidence from
AT

multiple large randomized controlled trials (RCTs), both highly controlled and pragmatic, that ICS-formoterol reliever is
M
D

superior to SABA for reducing severe exacerbations. Evidence supporting ICS-SABA is comparatively limited: a single
TE

RCT comparing as-needed ICS-SABA and as-needed SABA in Steps 3–5, and a small proof-of-concept study with as-
H

needed-only ICS-SABA in Step 2; (b) the reduction in emergency department visits or hospitalizations with as-needed-
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only ICS-formoterol in patients previously taking SABA alone, low-dose ICS or LTRA: by 65% compared with SABA
PY

alone, and by 37% compared with daily ICS plus as-needed SABA; and (c) the simplicity of the Track 1 approach for
O

patients and clinicians, because the same medication is used for both symptom relief and, if needed, maintenance
C

treatment. Treatment can be adjusted up or down, when clinically appropriate, by adding/removing maintenance
doses, without needing to add a different medication or inhaler device.
• Practical guidance on medications and doses for GINA Track 1: More details have been provided in a new table
(Box 3-15, p.80). Details about doses are also included where relevant throughout the report, including in sections on
treatment steps (starting on p.68), and asthma action plans (p.142). This information has been added in response to
requests by clinicians and academics, and to address incorrect advice about dosage of ICS-formoterol in some
commonly used external clinical resources. We also cite an article written by authors from GINA and the 2020 NAEPP
Focused Updates to US asthma guidelines,8 which provides practical advice about MART for clinicians, including a
template for a written asthma action plan customized for use with this regimen.

• Update of GINA 2023 treatment figure for children 6–11 years (Box 3-13, p.66): Mepolizumab, an anti-
interleukin-5 antibody given by subcutaneous injection, has been added to the preferred maintenance treatment
options at Step 5 for children with severe eosinophilic asthma, after specialist referral and optimization of treatment. A

What’s new in GINA 2023? 17

 double-blind RCT in urban children taking high dose ICS or ICS-LABA demonstrated a reduction in severe
exacerbations with add-on mepolizumab compared with placebo (p.133).

• Clarification of GINA 2023 treatment figure for children 5 years and younger (Box 6-6, p.183): To avoid
confusion, the Step 1 box for ‘Preferred controller’ now states that there is ‘Insufficient evidence for maintenance
treatment’.
• Addition of environmental considerations for inhaler choice: The section about choice of inhalers has been
expanded, and a new figure added (Box 3-21, p.99), with more details about the issues that should be considered,
including the environmental impact of the inhalers themselves. The issues include, first, choosing the most appropriate
medication for the patient to reduce exacerbations and control symptoms and then, from the inhalers available for that
medication, assessing which inhaler the patient can use correctly after training; if there is more than one option, which
of them has the lowest environmental impact, and whether the patient is satisfied with the inhaler. Reducing the risk of
asthma exacerbations is a high-priority objective because of their burden to patients and to the healthcare system;
urgent health care also has a high environmental impact. As always, GINA stresses the importance of regularly

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checking inhaler technique for every patient, and correcting it when faulty.

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IB
• Additional advice on management of asthma in low- and middle-income countries: Advice has been provided

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about management of asthma in countries that lack access to essential inhaled asthma medications (p.112).9 GINA is

IS
actively contributing to international efforts to improve access to affordable essential asthma medications for all.4,5,7,10

D
R
• Updated advice on definition of mild asthma: Further discussion has been added about the limitations of the

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current retrospective definition of mild asthma, and the contrast between this academic definition and the common
PY
usage of ‘mild asthma’ in respiratory literature and in clinical practice. Interim advice about how to describe asthma
O
C
severity in various scenarios (clinical practice, education of health professionals, epidemiologic studies and clinical
T
O

trials) has been expanded and clarified (p.42). GINA is continuing discussion on this topic with a range of groups,
N

including patients and primary and specialist health professionals.

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-D

• Updated guidance on managing severe asthma: This includes clarification that, regardless of regulatory approvals,
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GINA recommends biologic therapy for asthma only if asthma is severe, and only if existing treatment has been
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optimized. The sections about classes of biologic therapy in Chapter 3.5 provide a brief summary of the now-extensive
AT

evidence base, not a detailed review. Because of the variability between populations, settings and background
M

exacerbation rates in different studies of biologic therapies, specific results are reported from meta-analyses as a
D

general indication of magnitude of effect, but not from individual studies, with the exception of data on OCS reduction.
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With expanding indications for biologic therapy, additional non-asthma indications are mentioned only if they are
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relevant to asthma management, or if the condition is commonly associated with asthma. Other updates in Chapter
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3.5 include the recommendation for mepolizumab in children aged ≥6 years with eosinophilic asthma, noted above;
PY

and a double-blind study of withdrawal of mepolizumab in adults with eosinophilic asthma, that found more
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C

exacerbations in those who ceased mepolizumab than those who continued treatment (p.136).

• New practical guide to management of asthma exacerbations: Following multiple requests, additional details have
been added about medications and doses for as-needed ICS-formoterol and as-needed ICS-SABA in the section on
written asthma action plans, together with a reference for a downloadable action plan customized for maintenance and
reliever therapy (MART) with ICS-formoterol (p.142). Information has also been added about studies supporting the
use of budesonide-formoterol for acute asthma in emergency department settings (p.150).
Safety issues

• Pulse oximetry: the FDA has issued a safety communication about the potential overestimation of oxygen saturation
from pulse oximetry in people with dark skin color (p.151).

• Advice about potential drug interactions between anti-COVID-19 treatment such as ritonavir-boosted nirmatrelvir
(NMV/r) and asthma medications including ICS-salmeterol and ICS-vilanterol. This advice is included because several
key drug interaction websites recommend that LABAs should be stopped if NMV/r is prescribed, without advising that

18 What’s new in GINA 2023?

 this could result in an asthma exacerbation. Advice about drug interactions has also been added in the section about
management of allergic bronchopulmonary aspergillosis (p.118).
Other changes include the following:
o Imaging: a brief section has been added about the role of imaging in the diagnosis of asthma (p.28).
o Pertussis has been added as a differential diagnosis for asthma (p.30), and for exacerbations of asthma (p.139).
o Asthma Control Questionnaire (ACQ): GINA again advises use of the 5-item version (ACQ-5), rather than ACQ-6
or ACQ-7 (p.37). Data for ACQ-5, ACQ-6 and ACQ-7 cannot be combined for meta-analysis.
o Composite asthma control tools: Because patients with good symptom control can still be at risk of severe
exacerbations, and because of the many modifiable risk factors for exacerbations that are independent of
symptom control (Box 2-2B, p.38), GINA does not recommend assessment tools that combine symptom control
with exacerbation history; both symptom control and individual risk factors should be assessed (p.35).
o Advice about managing asthma during the COVID-19 pandemic: Advice has been added about management of

TE
asthma if patients acquire COVID-19, including potential drug interactions (p.118).

U
o FeNO-guided treatment: A well-conducted multinational study in children found that adding FeNO to symptom-

IB
TR
guided treatment did not result in fewer exacerbations (p.84). Updates of the 2016 Cochrane reviews on this topic

IS
to include additional studies in children and adults are awaited.

D
R
o Update of evidence on digital interventions for adherence: A Cochrane review found that a variety of digital

O
intervention strategies improved adherence to maintenance asthma medications, reduced exacerbations, and
PY
improved asthma control, in studies of up to 2 years’ duration in adults and children. Effective interventions
O
C
included electronic monitoring of maintenance inhaler use and text messages (p.101).
T

o Nasal and sinus disease: this material (p.108) has been divided into separate sections about rhinitis and sinusitis,
O
N

and chronic rhinosinusitis with and without nasal polyps (CRSwNP and CRSsNP respectively).
O
-D

o Transitioning of adolescents from pediatric to adult care: Additional information has been provided about important
issues to consider during this vulnerable period, based on new guidelines from the European Academy of Allergy
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and Clinical Immunology (p.113)

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o Fragility fractures: the cumulative adverse effects of exposure to oral corticosteroids include not just osteoporosis,
AT

but also fragility fractures, which in the elderly can have serious effects on quality of life, and often require
M
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healthcare utilization. The risk of fragility fractures has been included in several places.
TE

o Non-pharmacologic strategies: New evidence has been included about the benefit of physical activity in adults with
H
IG

moderate/severe asthma (p.90). A systematic review of comprehensive social risk interventions in the USA found
R

a reduction in emergency room visits. Evidence from other countries and settings is needed (p.95).
PY

o Outdoor air pollution: use of digital monitoring devices identified an impact of higher pollution on asthma
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C

medication utilization, with a lag of 0–3 days (p.95). This may be useful in predicting need for additional resources
at healthcare facilities.
o Vaccinations: additional evidence is included about the safety of influenza vaccination in people with asthma.
There is insufficient evidence to recommend routine pneumococcal or pertussis vaccination in adults (p.87).
Structure and format

• Appendix: The Appendix will be replaced by a yearly supplement published after the GINA Strategy Report,
explaining the evidence and rationale for recent major changes in more detail than is possible in this ‘What’s New’
summary. Appendices published up to 2020 are available in the online archive.
• Treatment steps for adults, adolescents and children 6–11 years: Information in Chapter 3.2 about new or
updated treatment recommendations has been restructured, where possible, to provide details under the headings of
population, evidence, other considerations and practice points.

What’s new in GINA 2023? 19

 • Boxes and tables: For simplicity, boxes (tables and figures) have been renumbered consecutively within each
chapter. Abbreviations have been removed from figures and tables to reduce crowding, and they are now included at
the beginning of the report, accessed by a hyperlink from underneath each Box. The publication year has been added
to the main treatment figures to help avoid external use of out-of-date versions.
• COVID-19: Given the marked reduction in COVID-19 cases in most countries, the section on management of asthma
during the pandemic has been moved to Chapter 3.3 (p.109).

• Short guide on difficult-to-treat and severe asthma: Chapter 3.5 of the GINA 2023 report about difficult-to-treat and
severe asthma, including the decision tree, will be published shortly as a stand-alone resource, now in a larger format
than the previous ‘pocket’ guide, to improve its readability and utility.
Topics still under discussion

• Diagnosis of asthma: Discussion is ongoing about the diagnosis of asthma in adults and in children, following review
of recent guidelines on diagnosis of asthma in children aged 5–16 years11 and in adults.12 Further work is needed to

TE
evaluate the utility for clinical practice of their consensus-based algorithms. Both algorithms recommended FeNO

U
testing instead of bronchodilator responsiveness testing for patients whose prebronchodilator lung function is above

IB
specified criteria; this would require testing on a second day, since FeNO must be performed before spirometry. The

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ATS/ERS technical standard on interpretive strategies for routine lung function tests13 was also reviewed. The authors

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D
recommended a change in the criterion for significant bronchodilator responsiveness in FEV1 or FVC to 10% of the

R
predicted value, but cautioned against over-reliance on strict cut-offs. As bronchodilator responsiveness defined by the

O
conventional criterion of change >12% and >200 mL was used as a gold standard for the evaluation of diagnostic tests
PY
by the above two guidelines groups, it would be helpful for the effect of the proposed new bronchodilator
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C
responsiveness criterion on the sensitivity and specificity of these diagnostic tests to be assessed. For the present, no
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changes have been made to the GINA box about diagnostic investigations (Box 1-2, p.25), except to reverse the order
N

of confirming variability in lung function, and confirming that there is evidence of expiratory airflow limitation, to
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address some ambiguity with the previous wording. The GINA diagnostic flow-chart (Box 1-2, p.24) starts by
assessing whether the patient or child’s symptoms are typical of asthma or more typical of other conditions, as the
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latter should prompt alternative investigations rather than necessarily proceeding to spirometry.
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• Assessment of symptom control: GINA continues to seek evidence relevant to the assessment of symptom control
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in patients whose reliever is ICS-formoterol.

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• Allergen immunotherapy: A review of updated evidence on subcutaneous allergen immunotherapy (SCIT) and
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sublingual immunotherapy (SLIT) for patients with asthma is nearing completion.

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• Severe asthma in children 6–11 years: a pocket guide is in development.

PY
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• Digital formats for GINA resources: investigation of digital options is ongoing, with the aim of facilitating access to
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GINA resources on portable devices and smartphones. Presentation of the GINA Strategy Report as an eBook is not
feasible at present because bibliographic referencing programs are not yet compatible with any of the current e-Book
platforms, so references would need to be re-entered manually every year.

• Advice about COVID-19 will be updated promptly on the GINA website as relevant information becomes available.
Note: minor corrections and clarifications 06 July 2023
• Box 3-9 (p.62): Text corrected: the preferred initial treatment for children 6–11 years with infrequent symptoms is ICS
taken whenever SABA is taken; the alternative is daily maintenance low-dose ICS plus as-needed SABA.
• Box 3-12 (p.65): Order of Track 2 reliever options reversed, and footnote edited, to clarify that anti-inflammatory
relievers comprise as-needed ICS-formoterol and as-needed ICS-SABA, but not SABA alone.
• Box 3-15 (p.80): Minor reformatting and table and text edits for clarity including that, for children 6–11 years, there is
no evidence for use of anti-inflammatory reliever alone in Step 1 or for MART in Step 5.
• A small number of minor corrections have been made to text, reference citation numbers and incomplete citations.

20 What’s new in GINA 2023?

 SECTION 1. ADULTS, ADOLESCENTS AND
CHILDREN 6 YEARS AND OLDER

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Chapter 1.

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Definition,
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description, and diagnosis

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of asthma
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KEY POINTS

What is asthma?
• Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the
history of respiratory symptoms, such as wheeze, shortness of breath, chest tightness and cough, that vary
over time and in intensity, together with variable expiratory airflow limitation. Airflow limitation may later become
persistent.
• Asthma is usually associated with airway hyperresponsiveness and airway inflammation, but these are not
necessary or sufficient to make the diagnosis.
• Recognizable clusters of demographic, clinical and/or pathophysiological characteristics are often called
‘asthma phenotypes’; however, these do not correlate strongly with specific pathological processes or treatment
responses.
How is asthma diagnosed?

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• The diagnosis of asthma is based on the history of characteristic symptom patterns and evidence of variable

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expiratory airflow limitation. This should be documented from bronchodilator reversibility testing or other tests.

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• Test before treating, wherever possible, i.e. document the evidence for the diagnosis of asthma before starting

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ICS-containing treatment, as it is often more difficult to confirm the diagnosis once asthma control has

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improved.

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Additional or alternative strategies may be needed to confirm the diagnosis of asthma in particular populations,
PY
•
including patients already on ICS-containing treatment, the elderly, and those in low-resource settings.
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C
T
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DEFINITION OF ASTHMA
N
O
-D

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history
of respiratory symptoms, such as wheeze, shortness of breath, chest tightness and cough, that vary over time and in
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intensity, together with variable expiratory airflow limitation.

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This definition was reached by consensus, based on consideration of the characteristics that are typical of asthma
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before ICS-containing treatment is commenced, and that distinguish it from other respiratory conditions. However,
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airflow limitation may become persistent later in the course of the disease.
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H
IG

DESCRIPTION OF ASTHMA
R
PY

Asthma is a common, chronic respiratory disease affecting 1–29% of the population in different countries.14,15 Asthma is
O

characterized by variable symptoms of wheeze, shortness of breath, chest tightness and/or cough, and by variable
C

expiratory airflow limitation. Both symptoms and airflow limitation characteristically vary over time and in intensity. These
variations are often triggered by factors such as exercise, allergen or irritant exposure, change in weather, or viral
respiratory infections.
Symptoms and airflow limitation may resolve spontaneously or in response to medication, and may sometimes be
absent for weeks or months at a time. On the other hand, patients can experience episodic flare-ups (exacerbations) of
asthma that may be life-threatening and carry a significant burden to patients and the community. The majority of
asthma deaths occur in low- and middle-income countries.4 Asthma is usually associated with airway
hyperresponsiveness to direct or indirect stimuli, and with chronic airway inflammation. These features usually persist,
even when symptoms are absent or lung function is normal, but may normalize with treatment.

Asthma phenotypes
Asthma is a heterogeneous disease, with different underlying disease processes. Recognizable clusters of
demographic, clinical and/or pathophysiological characteristics are often called ‘asthma phenotypes’.16-18 In patients with

22 1. Definition, description and diagnosis of asthma

 more severe asthma, some phenotype-guided treatments are available. However, except in patients with severe
asthma, no strong relationship has been found between specific pathological features and particular clinical patterns or
treatment responses. More research is needed to understand the clinical utility of phenotypic classification in asthma.
Many clinical phenotypes of asthma have been identified.16-18 Some of the most common are:
• Allergic asthma: this is the most easily recognized asthma phenotype, which often commences in childhood and is
associated with a past and/or family history of allergic disease such as eczema, allergic rhinitis, or food or drug
allergy. Examination of the induced sputum of these patients before treatment often reveals eosinophilic airway
inflammation. Patients with this asthma phenotype usually respond well to inhaled corticosteroid (ICS) treatment.
• Non-allergic asthma: some patients have asthma that is not associated with allergy. The cellular profile of the sputum
of these patients may be neutrophilic, eosinophilic or contain only a few inflammatory cells (paucigranulocytic).
Patients with non-allergic asthma often demonstrate a lesser short-term response to ICS.
• Adult-onset (late-onset) asthma: some adults, particularly women, present with asthma for the first time in adult life.
These patients tend to be non-allergic, and often require higher doses of ICS or are relatively refractory to
corticosteroid treatment. Occupational asthma (i.e. asthma due to exposures at work) should be ruled out in patients

TE
presenting with adult-onset asthma.

U
IB
• Asthma with persistent airflow limitation: some patients with long-standing asthma develop airflow limitation that is

TR
persistent or incompletely reversible. This is thought to be due to airway wall remodeling.

IS
• Asthma with obesity: some obese patients with asthma have prominent respiratory symptoms and little eosinophilic

D
R
airway inflammation.

O
PY
There is little evidence about the natural history of asthma after diagnosis, but one longitudinal study showed that
O
approximately 16% of adults with recently diagnosed asthma may experience clinical remission (no symptoms or
C
asthma medication for at least 1 year) within 5 years.19
T
O
N

MAKING THE INITIAL DIAGNOSIS

O
-D

Making the diagnosis of asthma before treatment is started, as shown in Box 1-1 (p.24) is based on identifying both a
L

characteristic pattern of respiratory symptoms such as wheezing, shortness of breath (dyspnea), chest tightness or
IA
ER

cough, and variable expiratory airflow limitation.20 The pattern of symptoms is important, as respiratory symptoms may
AT

be due to acute or chronic conditions other than asthma (see Box 1-3 (p.30). If possible, the evidence supporting a
M

diagnosis of asthma (Box 1-2, p.25) should be documented when the patient first presents, as the features that are
D

characteristic of asthma may improve spontaneously or with treatment. As a result, it is often more difficult to confirm a
TE

diagnosis of asthma once the patient has been started on ICS-containing treatment, because this reduces variability of
H
IG

both symptoms and lung function.

R
PY

Patterns of respiratory symptoms that are characteristic of asthma

O
C

The following features are typical of asthma and, if present, increase the probability that the patient has asthma:20
Respiratory symptoms of wheeze, shortness of breath, cough and/or chest tightness:
• Patients (especially adults) experience more than one of these types of symptoms.
• Symptoms are often worse at night or in the early morning.
• Symptoms vary over time and in intensity.
• Symptoms are triggered by viral infections (colds), exercise, allergen exposure, changes in weather, laughter, or
irritants such as car exhaust fumes, smoke or strong smells.
The following features decrease the probability that respiratory symptoms are due to asthma:
• Isolated cough with no other respiratory symptoms (see p.31)
• Chronic production of sputum
• Shortness of breath associated with dizziness, light-headedness or peripheral tingling (paresthesia)
• Chest pain
• Exercise-induced dyspnea with noisy inspiration.

1. Definition, description and diagnosis of asthma 23

Box 1-1. Diagnostic flowchart for clinical practice

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

PEF: peak expiratory flow (highest of three readings). When measuring PEF, use the same meter each time as the value may vary by up to 20%
between different meters; prn: as-needed. See list of abbreviations (p.10).

Bronchodilator responsiveness (reversibility) may be lost during severe exacerbations or viral infections, and in long-standing asthma, and it usually
decreases with inhaled corticosteroid treatment. If bronchodilator responsiveness is not found at initial presentation, the next step depends on the
availability of tests and the clinical urgency of need for treatment.

24 1. Definition, description and diagnosis of asthma

Box 1-2. Diagnostic criteria for asthma in adults, adolescents, and children 6–11 years

1. HISTORY OF TYPICAL VARIABLE RESPIRATORY SYMPTOMS

Feature
Wheeze, shortness of breath,
chest tightness and cough
(Descriptors may vary between
cultures and by age)
Symptoms or features that support the diagnosis of asthma
• More than one type of respiratory symptom (in adults, isolated cough is seldom
due to asthma)
• Symptoms occur variably over time and vary in intensity
• Symptoms are often worse at night or on waking
• Symptoms are often triggered by exercise, laughter, allergens, cold air
• Symptoms often appear or worsen with viral infections

2. CONFIRMED VARIABLE EXPIRATORY AIRFLOW LIMITATION

Feature Considerations, definitions, criteria

TE
1. Documented* excessive The greater the variations, or the more occasions excess variation is seen, the more

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IB
variability in lung function* confident the diagnosis. If initially negative, tests can be repeated during symptoms

TR
(one or more of the following): or in the early morning.

IS
D
• Positive bronchodilator (BD) Adults: increase in FEV1 of >12% and >200 mL (greater confidence if increase is

R
responsiveness (reversibility) >15% and >400 mL). Children: increase in FEV1 from baseline of >12% predicted.

O
PY
test Measure change 10–15 minutes after 200–400 mcg salbutamol (albuterol) or
O
equivalent, compared with pre-BD readings. Positive test more likely if BD withheld
C
before test: SABA ≥4 hours, twice-daily LABA 24 hours, once-daily LABA 36 hours
T
O
N

• Excessive variability in twice- Adults: average daily diurnal PEF variability >10%*
O

daily PEF over 2 weeks Children: average daily diurnal PEF variability >13%*
-D

• Increase in lung function after 4 Adults: increase in FEV1 by >12% and >200 mL (or PEF† by >20%) from baseline
L
IA

weeks of treatment after 4 weeks of ICS-containing treatment, outside respiratory infections

ER
AT

• Positive exercise challenge test Adults: fall in FEV1 of >10% and >200 mL from baseline
M

Children: fall in FEV1 of >12% predicted, or PEF >15% from baseline

D
TE

• Positive bronchial challenge test Fall in FEV1 from baseline of ≥20% with standard doses of methacholine, or ≥15%
H

(usually only for adults) with standardized hyperventilation, hypertonic saline or mannitol challenge
IG
R

• Excessive variation in lung Adults: variation in FEV1 of >12% and >200 mL between visits, outside of respiratory
PY

function between visits (good infections. Children: variation in FEV1 of >12% in FEV1 or >15% in PEF† between
O
C

specificity but poor sensitivity) visits (may include respiratory infections)

AND
2 Documented* expiratory At a time when FEV1 is reduced (e.g. during testing above), confirm that FEV1/FVC is
airflow limitation also reduced compared with the lower limit of normal (it is usually >0.75–0.80 in
adults, >0.90 in children21)

See list of abbreviations (p.10). For bronchodilator responsiveness testing, use either a SABA or a rapid-acting ICS-LABA. See Box 1-3 (p.28) for how to
confirm the diagnosis in patients already taking ICS-containing treatment. *Daily diurnal PEF variability is calculated from twice daily PEF as (day’s
highest minus day’s lowest) divided by (mean of day’s highest and lowest), averaged over one week. For each PEF measurement, use the highest of 3
readings. †For PEF, use the same meter each time, as PEF may vary by up to 20% between different meters. BD responsiveness may be lost during
severe exacerbations or viral infections,22 and airflow limitation may become persistent over time. If reversibility is not present at initial presentation, the
next step depends on the availability of other tests and the urgency of the need for treatment. In a situation of clinical urgency, asthma treatment may be
commenced and diagnostic testing arranged within the next few weeks (Box 1-4, p.29), but other conditions that can mimic asthma (Box 1-5) should be
considered, and the diagnosis confirmed as soon as possible.

1. Definition, description and diagnosis of asthma 25

Why is it important to confirm the diagnosis of asthma?
This is important to avoid unnecessary treatment or over-treatment, and to avoid missing other important diagnoses. In
adults with an asthma diagnosis in the last 5 years, one-third could not be confirmed as having asthma after repeated
testing over 12 months and staged withdrawal of ICS-containing treatment. The diagnosis of asthma was less likely to
be confirmed in patients who had not had lung function testing performed at the time of initial diagnosis. Some patients
(2%) had serious cardiorespiratory conditions that had been misdiagnosed as asthma.23

History and family history

Commencement of respiratory symptoms in childhood, a history of allergic rhinitis or eczema, or a family history of
asthma or allergy, increases the probability that the respiratory symptoms are due to asthma. However, these features
are not specific for asthma and are not seen in all asthma phenotypes. Patients with allergic rhinitis or atopic dermatitis
should be asked specifically about respiratory symptoms.

Physical examination

TE
U
Physical examination in people with asthma is often normal. The most frequent abnormality is expiratory wheezing

IB
TR
(rhonchi) on auscultation, but this may be absent or only heard on forced expiration. Wheezing may also be absent

IS
during severe asthma exacerbations, due to severely reduced airflow (so called ‘silent chest’), but at such times, other

D
physical signs of respiratory failure are usually present. Wheezing may also be heard with inducible laryngeal

R
obstruction, chronic obstructive pulmonary disease (COPD), respiratory infections, tracheomalacia, or inhaled foreign

O
PY
body. Crackles (crepitations) and inspiratory wheezing are not features of asthma. Examination of the nose may reveal
O
signs of allergic rhinitis or nasal polyps.
C
T
O

Lung function testing to document variable expiratory airflow limitation

N
O

Asthma is characterized by variable expiratory airflow limitation, i.e., expiratory lung function varies over time, and in
-D

magnitude, to a greater extent than in healthy populations. In asthma, lung function may vary between completely
L

normal and severely obstructed in the same patient. Poorly controlled asthma is associated with greater variability in
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lung function than well-controlled asthma.22

AT

Lung function testing should be carried out by well-trained operators with well-maintained and regularly calibrated
M

equipment,24 with an inline filter to protect against transmission of infection.25 Forced expiratory volume in 1 second
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(FEV1) from spirometry is more reliable than peak expiratory flow (PEF). If PEF is used, the same meter should be used
H

each time, as measurements may differ from meter to meter by up to 20%.26

IG
R

A reduced FEV1 may be found with many other lung diseases (or poor spirometric technique), but a reduced ratio of
PY

FEV1 to forced vital capacity (FEV1/FVC), compared with the lower limit of normal, indicates expiratory airflow limitation.
O

Many spirometers now include multi-ethnic age-specific predicted values.21

C

In clinical practice, once an obstructive defect has been confirmed, variation in airflow limitation is generally assessed
from variation in FEV1 or PEF. ‘Variability’ refers to improvement and/or deterioration in symptoms and lung function.
Excessive variability may be identified over the course of one day (diurnal variability), from day to day, from visit to visit,
or seasonally, or from a reversibility test. ‘Reversibility’ (now called ‘responsiveness’)24 generally refers to rapid
improvements in FEV1 (or PEF), measured within minutes after inhalation of a rapid-acting bronchodilator such as
200–400 mcg salbutamol,27 or more sustained improvement over days or weeks after the introduction of treatment such
as ICS.27
In a patient with typical respiratory symptoms, obtaining evidence of excessive variability in expiratory lung function is an
essential component of the diagnosis of asthma. Some specific examples are:
• An increase in lung function after administration of a bronchodilator, or after a trial of ICS-containing treatment
• A decrease in lung function after exercise or during a bronchial provocation test
• Variation in lung function beyond the normal range when it is repeated over time, either on separate visits, or on
home monitoring over at least 1–2 weeks.

26 1. Definition, description and diagnosis of asthma

 Specific criteria for demonstrating excessive variability in expiratory lung function are listed in Box 1-2 (p.25). A decrease
in lung function during a respiratory infection, while commonly seen in asthma, does not necessarily indicate that a
person has asthma, as it may also be seen in otherwise healthy individuals or people with COPD.
How much variation in expiratory airflow is consistent with asthma?
There is overlap in bronchodilator reversibility and other measures of variation between health and disease.28 In a
patient with respiratory symptoms, the greater the variations in their lung function, or the more times excess variation is
seen, the more likely the diagnosis is to be asthma (Box 1-2, p.25). Generally, in adults with respiratory symptoms
typical of asthma, an increase or decrease in FEV1 of >12% and >200 mL from baseline, or (if spirometry is not
available) a change in PEF of at least 20%, is accepted as being consistent with asthma.
Diurnal PEF variability is calculated from twice daily readings as the daily amplitude percent mean, i.e.:
( [Day’s highest – day’s lowest] / mean of day’s highest and lowest) x 100
Then the average of each day’s value is calculated over 1–2 weeks. The upper 95% confidence limit of diurnal variability

TE
(amplitude percent mean) from twice daily readings is 9% in healthy adults,29 and 12.3% in healthy children,30 so in

U
general, diurnal variability >10% for adults and >13% for children is regarded as excessive.

IB
TR
If FEV1 is within the predicted normal range when the patient is experiencing symptoms, this reduces the probability that

IS
the symptoms are due to asthma. However, patients whose baseline FEV1 is >80% predicted can have a clinically

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R
important increase in lung function with bronchodilator or ICS-containing treatment. Predicted normal ranges (especially

O
for PEF) have limitations, so the patient’s own best reading (‘personal best’) is recommended as their ‘normal’ value.
PY
O
When can variable expiratory airflow limitation be documented?
C
T

If possible, evidence of variable expiratory airflow limitation should be documented before treatment is started. This is
O
N

because variability usually decreases with ICS treatment as lung function improves. In addition, any increase in lung
O

function after initiating ICS-containing treatment can help to confirm the diagnosis of asthma. Bronchodilator
-D

responsiveness may not be present between symptoms, during viral infections or if the patient has used a beta2-agonist
L

within the previous few hours; and in some patients, airflow limitation may become persistent or irreversible over time.
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If spirometry is not available, or variable expiratory airflow limitation is not documented, a decision about whether to
AT

investigate further or start ICS-containing treatment immediately depends on clinical urgency and access to other tests.
M

Box 1-3 (p.29) describes how to confirm the diagnosis of asthma in a patient already taking ICS-containing treatment.
D
TE
H

Other tests
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R

Bronchial provocation tests

PY
O

One option for documenting variable expiratory airflow limitation is to refer the patient for bronchial provocation testing to
C

assess airway hyperresponsiveness. Challenge agents include inhaled methacholine,31 histamine, exercise, 32 eucapnic
voluntary hyperventilation or inhaled mannitol. These tests are moderately sensitive for a diagnosis of asthma but have
limited specificity.31,32 For example, airway hyperresponsiveness to inhaled methacholine has been described in patients
with allergic rhinitis,33 cystic fibrosis,34 bronchopulmonary dysplasia35 and COPD.36 This means that a negative test in a
patient not taking ICS can help to exclude asthma, but a positive test does not always mean that a patient has asthma –
the pattern of symptoms (Box 1-2, p.25) and other clinical features (Box 1-3, p.28) must also be considered.
Allergy tests
The presence of atopy increases the probability that a patient with respiratory symptoms has allergic asthma, but this is
not specific for asthma nor is it present in all asthma phenotypes. Atopic status can be identified by skin prick testing or
by measuring the level of specific immunoglobulin E (sIgE) in serum. Skin prick testing with common environmental
allergens is simple and rapid to perform and, when performed by an experienced tester with standardized extracts, is
inexpensive and has a high sensitivity. Measurement of sIgE is no more reliable than skin tests and is more expensive,
but may be preferred for uncooperative patients, those with widespread skin disease, or if the history suggests a risk of

1. Definition, description and diagnosis of asthma 27

 anaphylaxis.37 The presence of a positive skin test or positive sIgE, however, does not mean that the allergen is causing
symptoms – the relevance of allergen exposure and its relation to symptoms must be confirmed by the patient’s history.
Imaging
Imaging studies are not routinely used in the diagnosis of asthma, but may be useful to investigate the possibility of
comorbid conditions or alternative diagnoses in adults with difficult-to-treat asthma. Imaging may also be used to identify
congenital abnormalities in infants with asthma-like symptoms, and alternative diagnoses in children with difficult-to-treat
asthma. High-resolution computed tomography (CT) of the lungs can identify conditions such as bronchiectasis,
emphysema, lung nodules, airway wall thickening and lung distension, and may assess airway distensibility. The
presence of radiographically detected emphysema is considered when differentiating asthma from COPD (Box 5-4,
p.166), but there is no accepted threshold and these conditions can coexist. Moreover, air trapping (which may be
present in asthma, and is also a feature of ageing) can be difficult to distinguish from emphysema. Chest imaging is not
currently recommended to predict treatment outcomes or lung function decline, or to assess treatment response.
CT of the sinuses can identify changes suggestive of chronic rhinosinusitis with or without nasal polyps (p.108), which in

TE
patients with severe asthma may help with choice of biologic therapy (see Box 3-28, p.125).

U
IB
TR
IS
Box 1-3. Steps for confirming the diagnosis of asthma in a patient already taking ICS-containing treatment

D
R
Current status Steps to confirm the diagnosis of asthma

O
PY
Variable respiratory Diagnosis of asthma is confirmed. Assess the level of asthma control (Box 2-2, p.38) and review
O
symptoms and variable ICS-containing treatment (Box 3-12, p.65, Box 3-13, p.66).
C
T

airflow limitation
O
N

Variable respiratory Consider repeating spirometry after withholding bronchodilator (4 hrs for SABA, 24 hrs for twice-
O
-D

symptoms but no daily ICS-LABA, 36 hrs for once-daily ICS-LABA) or during symptoms. Check between-visit
variable airflow variability of FEV1, and bronchodilator responsiveness. If still normal, consider other diagnoses
L
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limitation (Box 1-5, p.30).

ER

If FEV1 is >70% predicted: consider stepping down ICS-containing treatment (see Box 1-5) and
AT

reassess in 2–4 weeks, then consider bronchial provocation test or repeating bronchodilator
M

responsiveness.
D
TE

If FEV1 is <70% predicted: consider stepping up ICS-containing treatment for 3 months (Box 3-12,
H
IG

p.65), then reassess symptoms and lung function. If no response, resume previous treatment and
R

refer patient for diagnosis and investigation.

PY
O

Few respiratory Consider repeating BD responsiveness test again after withholding bronchodilator as above or
C

symptoms, normal lung
function, and no
variable airflow
limitation
Persistent shortness of
breath and persistent
airflow limitation
‘Variable airflow limitation’ refers to expiratory airflow. See list of abbreviations (p.10).
during symptoms. If normal, consider alternative diagnoses (Box 1-5, p.30).
Consider stepping down ICS-containing treatment (see Box 1-5):
• If symptoms emerge and lung function falls: asthma is confirmed. Step up ICS-containing
treatment to previous lowest effective dose.
• If no change in symptoms or lung function at lowest controller step: consider ceasing ICS-
containing, and monitor patient closely for at least 12 months (Box 3-16).
Consider stepping up ICS-containing treatment for 3 months (Box 3-12, p.65), then reassess
symptoms and lung function. If no response, resume previous treatment and refer patient for
diagnosis and investigation. Consider asthma–COPD overlap (Chapter 5, p.159).

28 1. Definition, description and diagnosis of asthma

CONFIRMING THE DIAGNOSIS OF ASTHMA IN PATIENTS ALREADY TAKING ICS-CONTAINING TREATMENT
If the basis of a patient’s diagnosis of asthma has not previously been documented, confirmation with objective testing
should be sought. Many patients (25–35%) with a diagnosis of asthma in primary care cannot be confirmed as having
asthma.23,38-41
The process for confirming the diagnosis in patients already on ICS-containing treatment depends on the patient’s
symptoms and lung function (Box 1-3, p.28). In some patients, this may include a trial of either a lower or a higher dose
of ICS-containing treatment. If the diagnosis of asthma cannot be confirmed, refer the patient for expert investigation
and diagnosis. For some patients, it may be necessary to step down the ICS-containing treatment in order to confirm the
diagnosis of asthma. The process is described in Box 1-4, p.29.

Box 1-4. How to step down ICS-containing treatment to help confirm the diagnosis of asthma

1. ASSESS

TE
• Document the patient’s current status including asthma control (Box 2-2, p.38) and lung function. If the patient has risk

U
IB
factors for asthma exacerbations (Box 2-2B), step down treatment only with close supervision.

TR
• Choose a suitable time (e.g., no respiratory infection, not going away on vacation, not pregnant).

IS
D
• Provide a written asthma action plan (Box 4-2, p.146) so the patient knows how to recognize and respond if symptoms

R
worsen. Ensure they have enough medication to resume their previous dose if their asthma worsens.

O
PY
2. ADJUST O
C

Show the patient how to reduce their ICS dose by 25–50%, or stop other maintenance medication (e.g., LABA,
T

•
O

leukotriene receptor antagonist) if being used. See step-down options in Box 3-16, p.83. Schedule a review visit for 2–
N
O

4 weeks.
-D

3. REVIEW RESPONSE
L
IA
ER

• Repeat assessment of asthma control and lung function tests in 2–4 weeks (Box 1-2, p.25).
AT

• If symptoms increase and variable expiratory airflow limitation is confirmed after stepping down treatment, the
M

diagnosis of asthma is confirmed. The patient should be returned to their lowest previous effective treatment.
D
TE

• If, after stepping down to a low-dose ICS-containing treatment, symptoms do not worsen and there is still no evidence
H

of variable expiratory airflow limitation, consider ceasing ICS-containing treatment and repeating asthma control
IG

assessment and lung function tests in 2–3 weeks, but follow the patient for at least 12 months.23
R
PY

See list of abbreviations (p.10).

O
C

1. Definition, description and diagnosis of asthma 29

DIFFERENTIAL DIAGNOSIS
The differential diagnosis in a patient with suspected asthma varies with age (Box 1-5). Any of these alternative
diagnoses may also be found together with asthma. See Chapter 3.4 (p.106) for management of multimorbidity.

Box 1-5. Differential diagnosis of asthma in adults, adolescents and children 6–11 years

Age Symptoms Condition

6–11 Sneezing, itching, blocked nose, throat-clearing Chronic upper airway cough syndrome
years Sudden onset of symptoms, unilateral wheeze Inhaled foreign body
Recurrent infections, productive cough Bronchiectasis
Recurrent infections, productive cough, sinusitis Primary ciliary dyskinesia
Cardiac murmurs Congenital heart disease
Pre-term delivery, symptoms since birth Bronchopulmonary dysplasia

TE
Excessive cough and mucus production, gastrointestinal symptoms Cystic fibrosis

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IB
12–39 Sneezing, itching, blocked nose, throat-clearing Chronic upper airway cough syndrome

TR
years Dyspnea, inspiratory wheezing (stridor) Inducible laryngeal obstruction

IS
D
Dizziness, paresthesia, sighing Hyperventilation, dysfunctional breathing

R
O
Productive cough, recurrent infections Bronchiectasis
Excessive cough and mucus production
PY Cystic fibrosis
O
C
Cardiac murmurs Congenital heart disease
T
O

Shortness of breath, family history of early emphysema Alpha1-antitrypsin deficiency

N

Sudden onset of symptoms Inhaled foreign body

O
-D

40+ Dyspnea, inspiratory wheezing (stridor) Inducible laryngeal obstruction

L

years Dizziness, paresthesia, sighing Hyperventilation, dysfunctional breathing

IA
ER

Cough, sputum, dyspnea on exertion, smoking or noxious exposure COPD*

AT

Productive cough, recurrent infections Bronchiectasis

M

Dyspnea with exertion, nocturnal symptoms, ankle edema Cardiac failure

D
TE

Treatment with angiotensin-converting enzyme (ACE) inhibitor Medication-related cough

H
IG

Dyspnea with exertion, non-productive cough, finger clubbing Parenchymal lung disease
R

Sudden onset of dyspnea, chest pain Pulmonary embolism

PY
O

Dyspnea, unresponsive to bronchodilators Central airway obstruction

C

All Chronic cough, hemoptysis, dyspnea; and/or fatigue, fever, (night) Tuberculosis
ages sweats, anorexia, weight loss
Prolonged paroxysms of coughing, sometimes stridor Pertussis
See list of abbreviations (p.10). *For more detail, see Chapter 5 (p.159). Any of the above conditions may also contribute to respiratory symptoms in
patients with confirmed asthma.

What is the role of exhaled nitric oxide in the diagnosis of asthma?

The fractional concentration of exhaled nitric oxide (FeNO) is modestly associated with levels of sputum and blood
eosinophils.42 FeNO has not been established as useful for ruling in or ruling out a diagnosis of asthma (defined on p.22)
because, while FeNO is higher in asthma that is characterized by Type 2 airway inflammation,43 it is also elevated in
non-asthma conditions (e.g. eosinophilic bronchitis, atopy, allergic rhinitis, eczema), and it is not elevated in some
asthma phenotypes (e.g. neutrophilic asthma). FeNO is lower in smokers and during bronchoconstriction44 and the early
phases of allergic response;45 it may be increased or decreased during viral respiratory infections.44 See Chapter 3.2,
p.57 for discussion about FeNO in the context of decisions about initial asthma treatment.

30 1. Definition, description and diagnosis of asthma

HOW TO MAKE THE DIAGNOSIS OF ASTHMA IN OTHER CONTEXTS

Patients presenting with persistent non-productive cough as the only respiratory symptom
Diagnoses to be considered are chronic upper airway cough syndrome (often called ‘postnasal drip’), cough induced by
angiotensin-converting enzyme (ACE) inhibitors, gastroesophageal reflux, chronic sinusitis, and inducible laryngeal
obstruction.46,47 Patients with so-called ‘cough-variant asthma’ have persistent cough as their principal or only symptom,
associated with airway hyperresponsiveness. It is often more problematic at night. Lung function may be normal, and for
these patients, documentation of variability in lung function (Box 1-2, p.25) is important.48 Cough-variant asthma must be
distinguished from eosinophilic bronchitis in which patients have cough and sputum eosinophilia but normal spirometry
and airway responsiveness.48

Occupational asthma and work-exacerbated asthma

Asthma acquired in the workplace is frequently missed. Asthma may be induced or (more commonly) aggravated by
exposure to allergens or other sensitizing agents at work, or sometimes from a single, massive exposure. Occupational

TE
rhinitis may precede asthma by up to a year and early diagnosis is essential, as persistent exposure is associated with

U
IB
worse outcomes.49,50

TR
IS
An estimated 5–20% of new cases of adult-onset asthma can be attributed to occupational exposure.49 Adult-onset

D
asthma requires a systematic inquiry about work history and exposures, including hobbies. Asking patients whether their

R
symptoms improve when they are away from work (weekends or vacation) is an essential screening question.51 It is

O
PY
important to confirm the diagnosis of occupational asthma objectively as it may lead to the patient changing their
O
occupation, which may have legal and socioeconomic implications. Specialist referral is usually necessary, and frequent
C
PEF monitoring at and away from work is often used to help confirm the diagnosis. Further information about
T
O

occupational asthma is found in Chapter 3 (p.116) and in specific guidelines.49

N
O
-D

Athletes
L

The diagnosis of asthma in athletes should be confirmed by lung function tests, usually with bronchial provocation
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testing.52 Conditions that may either mimic or be associated with asthma, such as rhinitis, laryngeal disorders
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(e.g., inducible laryngeal obstruction47), dysfunctional breathing, cardiac conditions and over-training, must be
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excluded.53
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Pregnant women
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Pregnant women and women planning a pregnancy should be asked whether they have asthma so that appropriate
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advice about asthma management and medications can be given (see Chapter 3: Managing asthma with multimorbidity
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and in specific populations, p.114).54 If objective confirmation of the diagnosis is needed, it would not be advisable to
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carry out a bronchial provocation test or to step down ICS-containing treatment until after delivery.

The elderly
Asthma is frequently undiagnosed in the elderly,55 due to poor perception of airflow limitation; acceptance of dyspnea as
being ‘normal’ in old age; lack of fitness; and reduced physical activity. The presence of multimorbidity also complicates
the diagnosis. In a large population based survey of asthma patients older than 65 years, factors associated with a
history of asthma hospitalization included co-diagnosis of COPD, coronary artery disease, depression, diabetes mellitus,
and difficulty accessing medications or clinical care because of cost.56 Symptoms of wheezing, breathlessness and
cough that are worse on exercise or at night can also be caused by cardiovascular disease or left ventricular failure,
which are common in this age group. A careful history and physical examination, combined with an electrocardiogram
and chest X-ray, will assist in the diagnosis.57 Measurement of plasma brain natriuretic polypeptide and assessment of
cardiac function with echocardiography may also be helpful.58 In older people with a history of smoking or biomass fuel
exposure, COPD and overlapping asthma and COPD (asthma–COPD overlap) should be considered (Chapter 5,
p.159).

1. Definition, description and diagnosis of asthma 31

Smokers and ex-smokers
Asthma and COPD may be difficult to distinguish in clinical practice, particularly in older patients and smokers and ex-
smokers, and these conditions may overlap (asthma-COPD overlap). The Global Strategy for Diagnosis, Management
and Prevention of COPD (GOLD) 202359 defines COPD on the basis of chronic respiratory symptoms, environmental
exposures such as smoking or inhalation of toxic particles or gases, with confirmation by post-bronchodilator
FEV1/FVC <0.7. Clinically important bronchodilator reversibility (>12% and >200 mL) is often found in COPD.60 Low
diffusion capacity is more common in COPD than asthma. The history and pattern of symptoms and past records can
help to distinguish these patients from those with long-standing asthma who have developed persistent airflow limitation
(see Chapter 5, p.159). Uncertainty in the diagnosis should prompt early referral for specialized investigation and
treatment recommendations, as patients with asthma-COPD overlap have worse outcomes than those with asthma or
COPD alone.61

Obese patients

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While asthma is more common in obese than non-obese people,62 respiratory symptoms associated with obesity can

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mimic asthma. In obese patients with dyspnea on exertion, it is important to confirm the diagnosis of asthma with

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objective measurement of variable expiratory airflow limitation. One study found that non-obese patients were just as

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likely to be over-diagnosed with asthma as obese patients (around 30% in each group).38 Another study found both

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over- and under-diagnosis of asthma in obese patients.63

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Low- and middle-income countries
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As described above, asthma is a clinical diagnosis, based on the history of characteristic symptom patterns and
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evidence of variable expiratory airflow limitation. However, in low- and middle-income countries (LMICs), access to lung
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function testing is often very limited, and even when available, may be substantially underused (e.g. unaffordable for the
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patient or health system,64 too time-consuming in a busy clinic, or impractical because requiring repeated visits of
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indigent patients.7
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In addition, in LMICs, the differential diagnosis of asthma may include other endemic respiratory disease
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(e.g., tuberculosis, HIV/AIDS-associated lung diseases, and parasitic or fungal lung diseases), so clinicians tend to
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place greater reliance on clinical findings and often use a syndromic approach to diagnosis and initial management.65
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This comes at the cost of precision but is based on the assumption (valid in most LMICs) that under-diagnosis and
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under-treatment of asthma is more likely66 than the overdiagnosis and overtreatment often seen in high income
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countries.23,67
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While acknowledging that poor access to lung function testing is a common barrier to asthma diagnosis in LMICs, GINA
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does not recommend that diagnosis should be solely based on syndromic clinical patterns. When spirometry is not
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available, the presence of variable expiratory airflow limitation (including reversible obstruction) can be confirmed by
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PEF (Box 1-2, p.25). The World Health Organization (WHO) Package of essential noncommunicable (PEN) disease
interventions for primary care68 lists the PEF meter as an essential tool in the management of chronic respiratory
diseases. WHO-PEN proposes use of PEF in support of a clinical diagnosis: a ≥20% improvement in PEF 15 minutes
after giving 2 puffs of albuterol increases the likelihood of a diagnosis of asthma versus COPD and other diagnoses.68
GINA also suggests that improvement in symptoms and PEF after a 4-week therapeutic trial with anti-inflammatory
therapy, with a 1-week course of oral corticosteroids if necessary, can help to confirm the diagnosis of asthma (or
prompt investigation for alternative diagnoses) before starting long-term ICS-containing treatment.
A structured algorithmic approach to patients presenting with respiratory symptoms forms part of several strategies
developed for improving respiratory disease management in LMICs.7 These strategies are of particular use in countries
where, owing to the high prevalence of tuberculosis, large numbers of patients with respiratory symptoms present for
assessment at tuberculosis clinics.
There is a pressing need for access to affordable diagnostic tools (peak flow meters and spirometry), and training in
their use, to be substantially scaled up in LMICs.9

32 1. Definition, description and diagnosis of asthma

 SECTION 1. ADULTS, ADOLESCENTS AND
CHILDREN 6 YEARS AND OLDER

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Chapter 2.
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Assessment of
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asthma
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KEY POINTS

Asthma control
• The level of asthma control is the extent to which the features of asthma can be observed in the patient, or
have been reduced or removed by treatment.
• Asthma control is assessed in two domains: symptom control and risk of adverse outcomes. Poor symptom
control is burdensome to patients and increases the risk of exacerbations, but patients with good symptom
control can still have severe exacerbations.
Asthma severity
• The current definition of asthma severity is based on retrospective assessment, after at least 2–3 months of
asthma treatment, from the treatment required to control symptoms and exacerbations.
• This definition is clinically useful for severe asthma, as it identifies patients whose asthma is relatively
refractory to conventional treatment with a combination of high-dose inhaled corticosteroid (ICS) and a long-

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acting beta2 agonist (LABA) and who may benefit from additional treatment such as biologic therapy. It is

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important to distinguish between severe asthma and asthma that is uncontrolled due to modifiable factors such

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as incorrect inhaler technique and/or poor adherence.

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• However, the clinical utility of a retrospective definition of mild asthma as ‘easy to treat’ is less clear, as

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patients with few interval symptoms can have exacerbations triggered by external factors such as viral

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infections or allergen exposure, and short-acting beta2 agonist (SABA)-only treatment is a significant risk factor
for exacerbations. PY
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• In clinical practice and in the general community, the term ‘mild asthma’ is often used to mean infrequent or
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mild symptoms, and patients often incorrectly assume that it means they are not at risk and do not need ICS-
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containing treatment.
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• For these reasons, GINA suggests that the term ‘mild asthma’ should generally be avoided in clinical practice
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or, if used, qualified with a reminder that patients with infrequent symptoms can still have severe or fatal
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exacerbations, and that this risk is substantially reduced with ICS-containing treatment.
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• GINA is continuing to engage in stakeholder discussions about the definition of mild asthma, to obtain
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agreement about the implications for clinical practice and clinical research of the changes in knowledge about
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asthma pathophysiology and treatment since the current definition of asthma severity was published.
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How to assess a patient with asthma

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• Assess symptom control from the frequency of daytime and night-time asthma symptoms, night waking and
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activity limitation and, for patients using SABA reliever, their frequency of SABA use. Other symptom control
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tools include Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ).
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• Also, separately, assess the patient’s risk factors for exacerbations, even if their symptom control is good. Risk
factors for exacerbations that are independent of symptom control include not only a history of ≥1 exacerbation
in the previous year, but also SABA-only treatment (without any ICS), over-use of SABA, socioeconomic
problems, poor adherence, incorrect inhaler technique, low forced expiratory volume in 1 second (FEV1),
exposures such as smoking, and blood eosinophilia. To date, there are no suitable composite tools for
assessing exacerbation risk.
• Also assess risk factors for persistent airflow limitation and medication side-effects, treatment issues such as
inhaler technique and adherence, and comorbidities, and ask the patient about their asthma goals and
treatment preferences.
• Once the diagnosis of asthma has been made, the main role of lung function testing is in the assessment of
future risk. It should be recorded at diagnosis, 3–6 months after starting treatment, and periodically thereafter.
• Investigate for impaired perception of bronchoconstriction if there are few symptoms but low lung function, and
investigate for alternative diagnoses if there are frequent symptoms despite good lung function.

34 2. Assessment of asthma
OVERVIEW
For every patient, assessment of asthma should include the assessment of asthma control (both symptom control and
future risk of adverse outcomes), treatment issues particularly inhaler technique and adherence, and any comorbidities
that could contribute to symptom burden and poor quality of life (Box 2-1, p.35). Lung function, particularly FEV1 as a
percentage of predicted, is an important part of the assessment of future risk.
The use of digital technology, telemedicine and telehealthcare in the monitoring of patients with asthma is rapidly
increasing, particularly during the COVID-19 pandemic. However, the types of interactions are diverse, and high-quality
studies are needed to evaluate their utility and effectiveness..
What is meant by ‘asthma control’?
The level of asthma control is the extent to which the manifestations of asthma can be observed in the patient, or have
been reduced or removed by treatment.29,69 It is determined by the interaction between the patient’s genetic background,
underlying disease processes, the treatment that they are taking, environment, and psychosocial factors.69

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Asthma control has two domains: symptom control and future risk of adverse outcomes (Box 2-2, p.38). Both should

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always be assessed. Lung function is an important part of the assessment of future risk; it should be measured at the

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start of treatment, after 3–6 months of treatment (to identify the patient’s personal best), and periodically thereafter for

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ongoing risk assessment.

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How to describe a patient’s asthma control

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Asthma control should be described in terms of both symptom control and future risk domains. For example:
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Ms X has good asthma symptom control, but she is at increased risk of future exacerbations because she has had a
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severe exacerbation within the last year. Mr Y has poor asthma symptom control. He also has several additional risk
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factors for future exacerbations including low lung function, current smoking, and poor medication adherence.
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What does the term ‘asthma control’ mean to patients?

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Many studies describe discordance between the patient’s and health provider’s assessment of the patient’s level of
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asthma control. This does not necessarily mean that patients ‘over-estimate’ their level of control or ‘under-estimate’ its
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severity, but that patients understand and use the word ‘control’ differently from health professionals, e.g. based on how
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quickly their symptoms resolve when they take reliever medication.69,70 If the term ‘asthma control’ is used with patients,
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the meaning should always be explained.

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Box 2-1. Assessment of asthma in adults, adolescents, and children 6–11 years
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1. Assess asthma control = symptom control and future risk of adverse outcomes
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• Assess symptom control over the last 4 weeks (Box 2-2A).

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• Identify any other risk factors for exacerbations, persistent airflow limitation or side-effects (Box 2-2B).
• Measure lung function at diagnosis/start of treatment, 3–6 months after starting ICS-containing treatment, then
periodically, e.g., at least once every 1–2 years, but more often in at-risk patients and those with severe asthma.
2. Assess treatment issues

• Document the patient’s current treatment step (Box 3-12, p.65).

• Watch inhaler technique (Box 3-22, p.100), assess adherence (Box 3-23, p.102) and side-effects.
• Check that the patient has a written asthma action plan.
• Ask about the patient’s attitudes and goals for their asthma and medications.
3. Assess multimorbidity

• Rhinitis, rhinosinusitis, gastroesophageal reflux, obesity, obstructive sleep apnea, depression and anxiety can
contribute to symptoms and poor quality of life, and sometimes to poor asthma control (see Chapter 3.4, p.106).

2. Assessment of asthma 35
ASSESSING ASTHMA SYMPTOM CONTROL
Asthma symptoms such as wheeze, chest tightness, shortness of breath and cough typically vary in frequency and
intensity, and contribute to the burden of asthma for the patient. Poor symptom control is also strongly associated with
an increased risk of asthma exacerbations.71-73
Asthma symptom control should be assessed at every opportunity, including during routine prescribing or dispensing.
Directed questioning is important, as the frequency or severity of symptoms that patients regard as unacceptable or
bothersome may vary from current recommendations about the goals of asthma treatment, and may differ from patient
to patient. For example, despite having low lung function, a person with a sedentary lifestyle may not experience
bothersome symptoms and so may appear to have good symptom control.
To assess symptom control (Box 2-2A) ask about the following in the past four weeks: frequency of asthma symptoms
(days per week), any night waking due to asthma or limitation of activity and, for patients using a SABA reliever,
frequency of its use for relief of symptoms. In general, do not include reliever taken before exercise, because some
people take this routinely without knowing whether they need it.

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Frequency of reliever use

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Historically, frequency of SABA reliever use (<2 or ≥2 days/week) has been included in the composite assessment of

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symptom control. This distinction was arbitrary, based on the assumption that if SABA was used on >2 days in a week,

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the patient needed to start maintenance ICS-containing therapy or increase the dose. In addition, higher average use of

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SABA over a year is associated with a higher risk of severe exacerbations,74,75 and in the shorter term, increasing use of
PY
as-needed SABA is associated with an increased likelihood of a severe exacerbation in subsequent days or weeks.76
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However, for patients prescribed an anti-inflammatory reliever (AIR) such as as-needed low-dose ICS-formoterol (GINA
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Track 1, Box 3-12, p.65), use of this reliever more than 2 days/week is already providing additional ICS therapy, so
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further dose escalation may not be needed. In addition, increasing use of as-needed ICS-formoterol is associated with a
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significantly lower risk of severe exacerbation in subsequent days or weeks compared with if the reliever is SABA,77,78 or
compared with if the patient is using SABA alone.79
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For these reasons, while the assessment of symptom control in Box 2-2A includes a criterion for SABA reliever use on
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≤2 versus >2 days/week, it does not include a similar criterion for an anti-inflammatory reliever such as as-needed ICS-
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formoterol. However, the patient’s average frequency of as-needed ICS-formoterol use over the past 4 weeks should be
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assessed, and taken into account when the patient’s maintenance ICS dose (or need for maintenance ICS-formoterol) is
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reviewed. This issue will be reviewed again when further data are available.
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Asthma symptom control tools for adults and adolescents

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Simple screening tools: these can be used in primary care to quickly identify patients who need more detailed
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assessment. Examples include the consensus-based GINA symptom control tool (Part A, Box 2-2A). This classification
correlates with assessments made using numerical asthma control scores.80,81 It can be used, together with a risk
assessment (Box 2-2B), to guide treatment decisions (Box 3-12, p.65). Other examples are the Primary Care Asthma
Control Screening Tool (PACS),82 and the 30-second Asthma Test, which also includes time off work/school.83
Categorical symptom control tools: e.g., the consensus-based ‘Royal College of Physicians (RCP) Three Questions’
tool,84 which asks about difficulty sleeping, daytime symptoms and activity limitation due to asthma in the previous
month. The Asthma APGAR tool includes a patient-completed asthma control assessment covering 5 domains: activity
limitations, daytime and nighttime symptom frequency (based on US criteria for frequency of night waking), triggers,
adherence, and patient-perceived response to treatment. This assessment is linked to a care algorithm for identifying
problems and adjusting treatment up or down. A study in the US showed that introduction of the Asthma APGAR tools
for patients aged 5–45 in primary care was associated with improved rates of asthma control; reduced asthma-related
urgent care, and hospital visits; and increased practices’ adherence to asthma management guidelines.85

36 2. Assessment of asthma
 Numerical ‘asthma control’ tools: these tools provide scores and cut points to distinguish different levels of symptom
control, validated against health care provider assessment. Many translations are available. These scores may be useful
for assessing patient progress; they are commonly used in clinical research, but may be subject to copyright restrictions.
Numerical asthma control tools are more sensitive to change in symptom control than categorical tools.80
Examples of numerical asthma control tools for assessing symptom control are:
• Asthma Control Questionnaire (ACQ):86,87 Scores range from 0–6 (higher is worse), with scores calculated as the
average from all questions. The authors stated that ACQ ≤0.75 indicated a high probability that asthma was well
controlled; 0.75–1.5 as a ‘grey zone’; and ≥1.5 a high probability that asthma was poorly controlled, based on
concepts of asthma control at the time; they later added that the crossover point between ‘well-controlled’ and ‘not
well-controlled’ asthma was close to 1.00.88 The 5-item ACQ (ACQ-5), comprises five symptom questions. Two
additional versions were published: ACQ-6 includes SABA frequency, and ACQ-7 also includes pre-bronchodilator
FEV1 % predicted. The minimum clinically important difference for all three versions of ACQ is 0.5.88 GINA prefers
ACQ-5 over ACQ-6 or 7 because the reliever question assumes regular rather than as-needed use of SABA, there is
no option between zero SABA use in a week and SABA use every day, and ACQ has not been validated with ICS-

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formoterol or ICS-SABA as the reliever. In addition, if ACQ-7 were to be used in adjustment of treatment, the

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inclusion of FEV1 in the composite score could lead to repeated step-up in ICS dose for patients with persistent

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airflow limitation. For these reasons, data for ACQ-5, ACQ-6 and ACQ-7 cannot be combined for meta-analysis.

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• Asthma Control Test (ACT):81,89,90 Scores range from 5–25 (higher is better). Scores of 20–25 are classified as well-

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controlled; 16–19 as not well-controlled; and 5–15 as very poorly controlled asthma. The ACT has four symptom/

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reliever questions plus patient self-assessed control. The minimum clinically important difference is 3 points.90

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Because patients with good symptom control can still be at risk of future severe exacerbations or asthma-related death,
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and because of the many modifiable risk factors for exacerbations that are independent of symptom control (Box 2-2B,
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p.38), GINA does not recommend assessment tools that combine symptom control with exacerbation history.
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When different tools are used for assessing asthma symptom control, the results correlate broadly with each other, but
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are not identical. Respiratory symptoms may be non-specific so, when assessing changes in symptom control, it is
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important to clarify that symptoms are due to asthma.

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Asthma symptom control tools for children aged 6–11 years

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In children, as in adults, assessment of asthma symptom control is based on symptoms, limitation of activities and use
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of rescue medication. Careful review of the impact of asthma on a child’s daily activities, including sports, play and social
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life, and on school absenteeism, is important. Many children with poorly controlled asthma avoid strenuous exercise so
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their asthma may appear to be well controlled. This may lead to poor fitness and a higher risk of obesity.
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Children vary considerably in the degree of airflow limitation observed before they complain of dyspnea or use their
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reliever therapy, and marked reduction in lung function is often seen before it is recognized by the parent or caregiver.
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They may report irritability, tiredness, and changes in mood in their child as the main problems when the child’s asthma
is not controlled. Parents/caregivers have a longer recall period than children, who may recall only the last few days;
therefore, it is important to include information from both the parent/caregiver and the child when the level of symptom
control is being assessed.
Several numeric asthma control scores have been developed for children. These include:
• Childhood Asthma Control Test (c-ACT)91 with separate sections for parent/caregiver and child to complete
• Asthma Control Questionnaire (ACQ)92,93
Some asthma control scores for children include history of exacerbations with symptoms, but these may have the same
limitations as described above for adults. They include the Test for Respiratory and Asthma Control in Kids (TRACK)94-96
and the Composite Asthma Severity Index (CASI).97
The results of these various tests correlate to some extent with each other and with the GINA classification of symptom
control. Box 2-3 (p.39) provides more details about assessing asthma control in children.

2. Assessment of asthma 37
Box 2-2. GINA assessment of asthma control in adults, adolescents and children 6–11 years
A. Asthma symptom control

Well Partly Uncontrolled

In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more than twice/week? Yes No
• Any night waking due to asthma? Yes No None of 1–2 of 3–4 of
• SABA* reliever for symptoms more than twice/week? Yes No these these these

• Any activity limitation due to asthma? Yes No

B. Risk factors for poor asthma outcomes

Assess risk factors at diagnosis and periodically, particularly for patients experiencing exacerbations.
Measure FEV1 at start of treatment, after 3–6 months of ICS-containing treatment to record the patient’s personal best
lung function, then periodically for ongoing risk assessment.

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a. Risk factors for exacerbations

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Uncontrolled

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Having uncontrolled asthma symptoms is an important risk factor for exacerbations.98
asthma symptoms

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Medications High SABA use (≥3 x 200-dose canisters/year associated with increased risk of

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exacerbations, increased mortality particularly if ≥1 canister per
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month)74,75,99,100
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Inadequate ICS: not prescribed ICS, poor adherence,101 or incorrect inhaler

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technique102
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N

Factors that Other medical Obesity,103,104 chronic rhinosinusitis,104 GERD,104 confirmed food allergy,105
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increase the risk conditions pregnancy106

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of exacerbations Exposures Smoking,107 e-cigarettes,108 allergen exposure if sensitized,107 air pollution109-112

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even if the patient

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Psychosocial Major psychological or socioeconomic problems113,114

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has few asthma

symptoms† Lung function Low FEV1 (especially <60% predicted),107,115 high bronchodilator
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responsiveness104,116,117
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Type 2 Higher blood eosinophils,104,118,119 elevated FeNO (in adults with allergic
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inflammatory asthma taking ICS)120

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markers
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Exacerbation Ever intubated or in intensive care unit for asthma,121 ≥1 severe exacerbation
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history in last 12 months122,123

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b. Risk factors for developing persistent airflow limitation

History Preterm birth, low birth weight and greater infant weight gain,124 chronic mucus
hypersecretion125,126
Medications Lack of ICS treatment in patient with history of severe exacerbation127
Exposures Tobacco smoke,125 noxious chemicals; occupational or domestic exposures49
Investigation findings Low initial FEV1,126 sputum or blood eosinophilia126

c. Risk factors for medication side-effects

Systemic Frequent OCS, long-term, high-dose and/or potent ICS, P450 inhibitors128
Local High-dose or potent ICS,128,129 poor inhaler technique130

See list of abbreviations (p.10). *Based on SABA (as-needed ICS-formoterol reliever not included); see page 36; excludes reliever taken before
exercise. †‘Independent’ risk factors are those that are significant after adjustment for the level of symptom control. Cytochrome P450 inhibitors
such as ritonavir, ketoconazole, itraconazole may increase systemic exposure to some types of ICS and some LABAs; see drug interaction
websites and p.111 for details. For children 6–11 years, also refer to Box 2-3, p.39. See Box 3-17, p.85 for specific risk reduction strategies.

38 2. Assessment of asthma
 Box 2-3. Specific questions for assessment of asthma in children 6–11 years
Asthma symptom control
Day symptoms Ask: How often does the child have cough, wheeze, dyspnea or heavy breathing (number of times
per week or day)? What triggers the symptoms? How are symptoms managed?
Night symptoms Cough, awakenings, tiredness during the day? (If the only symptom is cough, consider other
diagnoses such as rhinitis or gastroesophageal reflux disease).
Reliever use How often is reliever medication used? (check date on inhaler or last prescription) Distinguish
between pre-exercise use (sports) and use for relief of symptoms.
Level of activity What sports/hobbies/interests does the child have, at school and in their spare time? How does the
child’s level of activity compare with their peers or siblings? How many days is the child absent from
school? Try to get an accurate picture of the child’s day from the child without interruption from the
parent/caregiver.
Risk factors for adverse outcomes
Exacerbations Ask: How do viral infections affect the child’s asthma? Do symptoms interfere with school or sports?

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How long do the symptoms last? How many episodes have occurred since their last medical

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review? Any urgent doctor/emergency department visits? Is there a written action plan? Risk

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factors for exacerbations include a history of exacerbations, poor symptom control, poor adherence

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and poverty,123 and persistent bronchodilator reversibility even if the child has few symptoms.117

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Lung function Check curves and technique. Main focus is on FEV1 and FEV1/FVC ratio. Plot these values as
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percent predicted to see trends over time.
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Side-effects Check the child’s height at least yearly, as poorly controlled asthma can affect growth,131 and
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growth velocity may be lower in the first 1–2 years of ICS treatment.132 Ask about frequency and
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dose of ICS and OCS.

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Treatment factors
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Inhaler Ask the child to show how they use their inhaler. Compare with a device-specific checklist.
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technique
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Adherence Is there any of the child’s prescribed maintenance medication (inhalers and/or tablets) in the home
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at present? On how many days in a week does the child use it (e.g., 0, 2, 4, 7 days)? Is it easier to
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remember to use it in the morning or evening? Where is the medication kept – is it in plain view to
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reduce forgetting? Check date on inhaler.

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Goals/concerns Does the child or their parent or caregiver have any concerns about their asthma (e.g., fear of
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medication, side-effects, interference with activity)? What are their goals for treatment?
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Comorbidities
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Allergic rhinitis Itching, sneezing, nasal obstruction? Can the child breathe through their nose? What medications
are being taken for nasal symptoms?
Eczema Sleep disturbance, topical corticosteroids?
Food allergy Is the child allergic to any foods? (Confirmed food allergy is a risk factor for asthma-related
death.105)
Obesity Check age-adjusted BMI. Ask about diet and physical activity.
Other investigations (if needed)
2-week diary If no clear assessment can be made based on the above questions, ask the child or
parent/caregiver to keep a daily diary of asthma symptoms, reliever use and peak expiratory flow
(best of three) for 2 weeks.
Exercise Provides information about airway hyperresponsiveness and fitness (Box 1-2, p.25). Only
challenge undertake a challenge if it is otherwise difficult to assess asthma control.
(laboratory)
See list of abbreviations (p.10).

2. Assessment of asthma 39
ASSESSING FUTURE RISK OF ADVERSE OUTCOMES
The second component of assessing asthma control (Box 2-2B, p.38) is to identify whether the patient is at risk of
adverse asthma outcomes, particularly exacerbations, persistent airflow limitation, and side-effects of medications
(Box 2-2B). Asthma symptoms, although an important outcome for patients, and themselves a strong predictor of
future risk of exacerbations, are not sufficient on their own for assessing asthma because:
• Asthma symptoms can be controlled by placebo or sham treatments133,134 or by inappropriate use of long-
acting beta2-agonist (LABA) alone,135 which leaves airway inflammation untreated.
• Respiratory symptoms may be due to other conditions such as lack of fitness, or comorbidities such as
inducible laryngeal obstruction.47
• Anxiety or depression may contribute to symptom reporting.
• Some patients have impaired perception of bronchoconstriction, with few symptoms despite low lung
function.136
Asthma symptom control and exacerbation risk should not be simply combined numerically, as poor control of
symptoms and of exacerbations may have different causes and may need different treatment approaches.

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Risk factors for exacerbations

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Poor asthma symptom control itself substantially increases the risk of exacerbations.71-73 However, several additional

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independent risk factors have been identified, i.e., factors that, when present, increase the patient’s risk of

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exacerbations even if symptoms are few. These risk factors (Box 2-2B, p.38) include a history of ≥1 exacerbation in

D
the previous year, poor adherence, incorrect inhaler technique, chronic sinusitis and smoking, all of which can be

R
O
assessed in primary care.137 The risk of severe exacerbations and mortality increases incrementally with higher
PY
SABA use, independent of treatment step.75 Prescribing of three or more 200-dose SABA inhalers in a year,
O

corresponding to more than daily use, is associated with an increased risk of severe exacerbations74,75 and, in one
C
T

study, increased mortality.75 Risk factors and comorbidities that are modifiable (or potentially modifiable) are
O

sometimes called ‘treatable traits’.138

N
O
-D

In children, the risk of exacerbations is greatly increased if there is a history of previous exacerbations; it is also
increased with poor symptom control, suboptimal drug regimen, comorbid allergic disease and poverty.123
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Risk factors for development of persistent airflow limitation

AT
M

The average rate of decline in FEV1 in non-smoking healthy adults is 15–20 mL/year.139 People with asthma may
D

have an accelerated decline in lung function and develop airflow limitation that is not fully reversible. This is often
TE

associated with more persistent dyspnea. Independent risk factors that have been identified for persistent airflow
H
IG

limitation include exposure to cigarette smoke or noxious agents, chronic mucus hypersecretion, and asthma
R

exacerbations in patients not taking ICS127 (see Box 2-2B, p.38). Children with persistent asthma may have reduced
PY

growth in lung function, and some are at risk of accelerated decline in lung function in early adult life.140
O
C

Risk factors for medication side-effects

Choices with any medication are based on the balance of benefit and risk. Most people using asthma medications
do not experience any side-effects. The risk of side-effects increases with higher doses of medications, but these are
needed in few patients. Systemic side-effects that may be seen with long-term, high-dose ICS include easy bruising,
an increase beyond the usual age-related risk of osteoporosis and fragility fractures, cataracts, glaucoma, and
adrenal suppression. Local side-effects of ICS include oral thrush and dysphonia. Patients are at greater risk of ICS
side-effects with higher doses or more potent formulations128,129 and, for local side-effects, with incorrect inhaler
technique.130
Drug interactions with asthma medications: concomitant treatment with cytochrome P450 inhibitors such as
ketoconazole, ritonavir, itraconazole, erythromycin and clarithromycin may increase the risk of ICS adverse effects
such as adrenal suppression, and with short-term use, may increase the risk of cardiovascular adverse effects of the
LABAs salmeterol and vilanterol (alone or in combination with ICS). Concomitant use of these medications is not
recommended (see also p.111).141

40 2. Assessment of asthma
ROLE OF LUNG FUNCTION IN ASSESSING ASTHMA CONTROL

Does lung function relate to other asthma control measures?

Lung function does not correlate strongly with asthma symptoms in adults142 or children.143 In some asthma control
tools, lung function is numerically averaged or added with symptoms,86,144 but if the tool includes several symptom
items, these can outweigh clinically important differences in lung function.145 In addition, low FEV1 is a strong
independent predictor of risk of exacerbations, even after adjustment for symptom frequency.
Lung function should be assessed at diagnosis or start of treatment, after 3–6 months of ICS-containing treatment to
assess the patient’s personal best FEV1, and periodically thereafter. For example, in most adult patients, lung
function should be recorded at least every 1–2 years, but more frequently in higher risk patients including those with
exacerbations and those at risk of decline in lung function (see Box 2-2B, p.38). Lung function should also be
recorded more frequently in children based on asthma severity and clinical course (Evidence D).
Once the diagnosis of asthma has been confirmed, it is not generally necessary to ask patients to withhold their
regular or as-needed medications before visits,29 but preferably the same conditions should apply at each visit.

TE
How to interpret lung function test results in asthma

U
IB
A low FEV1 percent predicted:

TR
• Identifies patients at risk of asthma exacerbations, independent of symptom levels, especially if FEV1 is

IS
<60% predicted107,115,146,147

D
R
• Is a risk factor for lung function decline, independent of symptom levels126
O
• If symptoms are few, suggests limitation of lifestyle, or poor perception of airflow limitation,148 which may be
PY

due to untreated airway inflammation.136

O
C

A ‘normal’ or near-normal FEV1 in a patient with frequent respiratory symptoms (especially when symptomatic):
T
O

• Prompts consideration of alternative causes for the symptoms; e.g., cardiac disease, or cough due to post-
N
O

nasal drip or gastroesophageal reflux disease (Box 1-3, p.28).

-D

Persistent bronchodilator responsiveness:

L
IA

• Finding significant bronchodilator responsiveness (increase in FEV1 >12% and >200 mL from baseline27) in
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a patient taking ICS-containing treatment, or who has taken a SABA within 4 hours, or a LABA within
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12 hours (or 24 hours for a once-daily LABA), suggests uncontrolled asthma.

M
D

In children, spirometry cannot be reliably obtained until age 5 years or more, and it is less useful than in adults.
TE

Many children with uncontrolled asthma have normal lung function between flare-ups (exacerbations).
H
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How to interpret changes in lung function in clinical practice

PY
O

With regular ICS treatment, FEV1 starts to improve within days, and reaches a plateau after around 2 months.149 The
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patient’s highest FEV1 reading (personal best) should be documented, as this provides a more useful comparison for
clinical practice than FEV1 percent predicted. If predicted values are used in children, measure their height at each
visit.
Some patients may have a faster than average decrease in lung function, and develop persistent (incompletely
reversible) airflow limitation. While a trial of higher dose ICS-LABA and/or systemic corticosteroids may be
appropriate to see if FEV1 can be improved, high doses should not be continued if there is no response.
The between-visit variability of FEV1 (up to 12% week to week or 15% year to year in healthy individuals27) limits its
use in adjusting asthma treatment or identifying accelerated decline in clinical practice. The minimal important
difference for improvement and worsening in FEV1 based on patient perception of change has been reported to be
about 10%.150,151

The role of short-term and long-term PEF monitoring

Once the diagnosis of asthma is made, short-term peak expiratory flow (PEF) monitoring may be used to assess
response to treatment, to evaluate triggers (including at work) for worsening symptoms, or to establish a baseline for
action plans. After starting ICS, personal best PEF (from twice daily readings) is reached on average within

2. Assessment of asthma 41
 2 weeks.152 Average PEF continues to increase, and diurnal PEF variability to decrease, for about 3 months.142,152
Excessive variation in PEF suggests suboptimal asthma control, and increases the risk of exacerbations.153
Long-term PEF monitoring is now generally only recommended for patients with severe asthma, or those with
impaired perception of airflow limitation.136,154-157 For clinical practice, displaying PEF results on a standardized chart
may improve accuracy of interpretation.158

ASSESSING ASTHMA SEVERITY

The current concept of asthma severity is based on ‘difficulty to treat’
The current concept of asthma severity, recommended by an ATS/ERS Task Force29,69 and included in most asthma
guidelines, is that asthma severity should be assessed retrospectively from how difficult the patient’s asthma is to
treat. This is reflected by the level of treatment required to control the patient’s symptoms and exacerbations, i.e.,
after at least several months of treatment:29,69,159 By this definition:
• Severe asthma is defined as asthma that remains uncontrolled despite optimized treatment with high-dose
ICS-LABA, or that requires high-dose ICS-LABA to prevent it from becoming uncontrolled. Severe asthma
must be distinguished from asthma that is difficult to treat due to inadequate or inappropriate treatment, or

TE
persistent problems with adherence or comorbidities such as chronic rhinosinusitis or obesity,159 as they

U
need very different treatment compared with if asthma is relatively refractory to high-dose ICS-LABA or even

IB
TR
oral corticosteroids (OCS).159 See Box 2-4 (p.45) for how to distinguish difficult-to-treat and severe asthma,

IS
and Chapter 3.5 (p.120) for more detail about assessment, referral and treatment in this population.

D
• Moderate asthma is currently defined as asthma that is well controlled with Step 3 or Step 4 treatment

R
e.g. with low- or medium-dose ICS-LABA in either treatment track.O
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• Mild asthma is currently defined as asthma that is well controlled with low-intensity treatment, i.e.,
O

as-needed low-dose ICS-formoterol, or low-dose ICS plus as-needed SABA.

C
T
O

By this retrospective definition, asthma severity cannot be assessed unless good asthma control has been achieved
N

and treatment stepped down to find the patient’s minimum effective dose at which their asthma remains well-
O
-D

controlled (p.83), or unless asthma remains uncontrolled despite at least several months of optimized maximal
L

therapy.
IA
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The terms ‘severe asthma’ and ‘mild asthma’ are often used with different meanings than this
AT

In the community and in primary care, the terms ‘severe’ or ‘mild’ asthma are more commonly based on the
M

frequency or severity of symptoms or exacerbations, irrespective of treatment. For example, asthma is commonly
D
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called ‘severe’ if patients have frequent or troublesome asthma symptoms, regardless of their treatment, and ‘mild
H

asthma’ is commonly used if patients do not have daily symptoms or if symptoms are quickly relieved.
IG
R

In epidemiological studies, asthma is often classified as ‘mild’, ‘moderate’ or ‘severe’ based only on the prescribed
PY

treatment by GINA or BTS Step, regardless of patients’ level of asthma control. This assumes that the prescribed
O
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treatment was appropriate for the patient’s needs, whereas asthma is often under-treated or over-treated.
Most clinical trials of biologic therapy enroll patients with asthma that is uncontrolled despite taking medium- or high-
dose ICS-LABA, but do not assess and treat contributory factors such as incorrect inhaler technique, poor
adherence, or comorbidities before considering the patient’s eligibility for enrolment.160,161 Some clinical trial
participants may therefore have ‘difficult-to-treat’, rather than severe asthma.
Some guidelines162,163 also retain an older classification of asthma severity based on symptom and SABA frequency,
night waking, lung function and exacerbations before ICS-containing treatment is started.29,69 This classification also
distinguishes between ‘intermittent’ and ‘mild persistent’ asthma, but this historical distinction was arbitrary: it was
not evidence-based, but was based on an untested assumption that patients with symptoms ≤2 days/week were not
at risk and would not benefit from ICS, so should be treated with SABA alone. However, it is now known that patients
with so-called ‘intermittent’ asthma can have severe or fatal exacerbations,164,165 and that their risk is substantially
reduced by ICS-containing treatment compared with SABA alone.166-168 Although this symptom-based classification
is stated to apply to patients not on ICS-containing treatment,162,163 it is often used more broadly. This can cause
confusion, as a patient’s asthma may be classified differently, and they may be prescribed different treatment,
depending on which definition the clinician uses.

42 2. Assessment of asthma
 For low resource countries without access to effective medications such as ICS, the World Health Organization
definition of severe asthma169 includes a category of ‘untreated severe asthma’. This category corresponds to
uncontrolled asthma in patients not taking any ICS-containing treatment.
The patient’s view of asthma severity
Patients may perceive their asthma as severe if they have intense or frequent symptoms, but this does not
necessarily indicate underlying severe disease, as symptoms and lung function can rapidly become well controlled
with commencement of ICS-containing treatment, or improved inhaler technique or adherence.29,69 Likewise,
patients often perceive their asthma as mild if they have symptoms that are easily relieved by SABA, or that are
infrequent.29,69 Of concern, patients often interpret the term ‘mild asthma’ to mean that they are not at risk of severe
exacerbations and do not need to take ICS-containing treatment. This is often described as patients
‘underestimating’ their asthma severity, but instead it reflects their different interpretation of the words ‘severity’ and
‘mild’ compared with the academic usage of these terms.29,69
How useful is the current retrospective definition of asthma severity?
The retrospective definition of severe asthma based on ‘difficulty to treat’ has been widely accepted in guidelines
and in specialist clinical practice. It has obvious clinical utility as it identifies patients who, because of their burden of

TE
disease and incomplete response to optimized conventional ICS-based treatment, may benefit from referral to a

U
IB
respiratory physician (if available) for further investigation, phenotyping, and consideration of additional treatment

TR
such as biologic therapy (See Chapter 3.5, p.120). It is appropriate to classify asthma as ‘difficult-to-treat’ rather than

IS
severe if there are modifiable factors such as incorrect inhaler technique, poor adherence or untreated comorbidities,

D
R
because asthma may become well controlled when such issues are addressed.29,69,159
O
PY
By contrast, the clinical utility of the retrospective definition of mild asthma is much less clear. There is substantial
O

variation in opinions about the specific criteria that should be used, for example whether FEV1 should be ≥80%
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predicted in order for asthma to be considered ‘mild’, and whether the occurrence of any exacerbation precludes a
T
O

patient’s asthma being classified as ‘mild’ for the next 12 months.170 There are too few studies of the underlying
N
O

pathology to discern whether isolated exacerbations necessarily imply greater inherent severity, especially given the
-D

contribution of external triggers such as viral infections or allergen exposure to sporadic exacerbations.
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Further, by this definition, asthma can be classified as ‘mild’ only after several months of ICS-containing treatment,
ER

and only if asthma is well-controlled on low-dose ICS or as-needed low-dose ICS-formoterol, so this definition clearly
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cannot be applied to patients with uncontrolled or partly controlled symptoms who are taking SABA. Finally,
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retrospective classification of asthma as mild appears of little value in deciding on future treatment. In addition, in the
D
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studies of as-needed ICS-formoterol, baseline patient characteristics such as daily reliever use, lower lung function
H

or history of exacerbations (or even baseline blood eosinophils or FeNO) did not identify patients who should instead
IG

be treated with daily ICS.171,172 Instead, decisions about ongoing treatment should be based upon the large evidence
R
PY

base about the efficacy and effectiveness of as-needed ICS-formoterol or daily ICS, together with an individualized
O

assessment of the patient’s symptom control, exacerbation risk, predictors of response, and patient preferences (see
C

Box 3-2, p.50).

However, the most urgent problem with the term ‘mild asthma’, regardless of how it is defined, is that it encourages
complacency, since both patients and clinicians often interpret ‘mild asthma’ to mean that the patient is at low risk
and does not need ICS-containing treatment. However, up to 30% of asthma exacerbations and deaths occur in
people with infrequent symptoms, for example, less than weekly or only on strenuous exercise.164,165
Interim advice about asthma severity descriptors
For clinical practice
GINA continues to support the current definition of severe asthma as asthma that remains uncontrolled despite
optimized treatment with high-dose ICS-LABA, or that requires high-dose ICS-LABA to prevent it from becoming
uncontrolled, and maintains the clinically important distinction between difficult-to-treat and severe asthma. See
Box 2-4 (p.45) and Chapter 3.5 (p.120) for more detail about assessment and treatment of such patients.
We suggest that in clinical practice, the term ‘mild asthma’ should generally be avoided, because of the common but
mistaken assumption by patients and clinicians that it equates to low risk. Instead, assess the patient’s symptom
control and risk factors on their current treatment (p.35), as well as multimorbidity and patient goals and preferences.

2. Assessment of asthma 43
 Explain that patients with infrequent or mild asthma symptoms can still have severe or fatal exacerbations if treated
with SABA alone,164,165 and that this risk is reduced by half to two-thirds with low-dose ICS or with as-needed low-
dose ICS-formoterol.166,167 Ensure that you prescribe ICS-containing therapy to reduce the patient’s risk of severe
exacerbations (Box 3-5, p.58), and treat any modifiable risk factors or comorbidities using pharmacologic or non-
pharmacologic strategies (see Box 3-17, p.85 and Box 3-18, p.88).
For health professional education
The term ‘apparently mild asthma’ may be useful to highlight the discordance between symptoms and risk. However,
be aware that in some languages ‘apparently’ translates to the opposite of the intended meaning. Explain that
‘asthma control’ tools such as ACQ and ACT assess only one domain of asthma control (p.40), and that patients
with infrequent interval symptoms are over-represented in studies of severe, near-fatal and fatal asthma
exacerbations.164,165 Always emphasize the need for and benefit from ICS-containing treatment in patients with
asthma, regardless of their symptom frequency, and even if they have no obvious additional risk factors.
For epidemiologic studies
If clinical details are not available, describe the prescribed (or dispensed) treatment, without imputing severity,
e.g., ‘patients prescribed SABA with no ICS’ rather than ‘mild asthma’. Since treatment options change over time,

TE
and may differ between guidelines, state the actual treatment class, rather than a treatment Step (e.g., ‘low-dose

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maintenance and reliever therapy with ICS-formoterol’ rather than ‘Step 3 treatment’).

TR
IS
For clinical trials

D
R
Describe the patient population by their level of asthma control and treatment, e.g., ‘patients with uncontrolled
O
asthma despite medium-dose ICS-LABA plus as-needed SABA’ rather than ‘moderate asthma’.
PY
O

Further discussion is clearly needed

C
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Given the importance of mild asthma and the discordance between its academic definition and the various ways that
O
N

the term is used in clinical practice, GINA is continuing to discuss these issues with a wide range of stakeholders.
O

The aim is to obtain agreement among patients, health professionals, researchers, industry and regulators about the
-D

implications for clinical practice and clinical research of current knowledge about asthma pathophysiology and
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treatment,29,69 and whether/how the term ‘mild asthma’ should be used in the future. Pending the outcomes of this
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discussion, no change has been made to use of the term ‘mild asthma’ elsewhere in this GINA Strategy Report.
AT
M

HOW TO DISTINGUISH BETWEEN UNCONTROLLED ASTHMA AND SEVERE ASTHMA

D
TE

Although good symptom control and minimal exacerbations can usually be achieved with ICS-containing treatment,
H

some patients will not achieve one or both of these goals even with a long period of high-dose therapy.144,159 In some
IG
R

patients this is due to truly refractory severe asthma, but in many others, it is due to incorrect inhaler technique, poor
PY

adherence, over-use of SABA, comorbidities, persistent environmental exposures, or psychosocial factors.

O
C

It is important to distinguish between severe asthma and uncontrolled asthma, as the latter is a much more common
reason for persistent symptoms and exacerbations, and may be more easily improved. Box 2-4 (p.45) shows the
initial steps that can be carried out to identify common causes of uncontrolled asthma. More details are given in
Section 3.5 (p.120) about investigation and management of difficult-to-treat and severe asthma, including referral to
a respiratory physician or severe asthma clinic where possible, and use of add-on treatment including biologic
therapy. The most common problems that need to be excluded before making a diagnosis of severe asthma are:
• Poor inhaler technique (up to 80% of community patients)102 (Box 3-22, p.100)
• Poor medication adherence173,174 (Box 3-23, p.102)
• Incorrect diagnosis of asthma, with symptoms due to alternative conditions such as inducible laryngeal
obstruction, cardiac failure or lack of fitness (Box 1-5, p.30)
• Multimorbidity such as rhinosinusitis, GERD, obesity and obstructive sleep apnea104,175 (Chapter 3.4, p.106)
• Ongoing exposure to sensitizing or irritant agents in the home or work environment.

44 2. Assessment of asthma
 Box 2-4. Investigating a patient with poor symptom control and/or exacerbations despite treatment

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U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
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See list of abbreviations (p.10). See Chapter 3.5 (p.120) for more details about assessment and management of difficult-to-treat and severe
ER

asthma.
AT
M
D
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H
IG
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PY
O
C

2. Assessment of asthma 45
C
O
PY
R
IG
H
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D
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ER
IA
L
-D
O
N
O
T
C
O
PY
O
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D
IS
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IB
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 SECTION 1. ADULTS, ADOLESCENTS AND
CHILDREN 6 YEARS AND OLDER

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IS
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Chapter 3.
O
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O
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O
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Treating asthma to
O
-D
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control symptoms
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and minimize risk

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H
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 This chapter is divided into five parts:
3.1. General principles of asthma management (p.48)
3.2. Medications and strategies for asthma symptom control and risk reduction
• Medications, including treatment steps (p.53)
• Treating modifiable risk factors (p.85)
• Non-pharmacological therapies and strategies (p.88)
3.3. Guided asthma self-management education and skills training (p.98)
• Information, inhaler choice, inhaler skills, adherence, written asthma action plan, self-monitoring, regular
review
3.4. Managing asthma with multimorbidity and in specific populations and contexts, including COVID-19 (p.106)
3.5. Difficult-to-treat and severe asthma in adults and adolescents (including decision tree) (p.120)
Management of worsening and acute asthma is described in Chapter 4 (p.139).

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3.1. GENERAL PRINCIPLES OF ASTHMA MANAGEMENT

IS
D
KEY POINTS

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O
Goals of asthma management
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O
• The long-term goals of asthma management are to achieve good symptom control, and to minimize future risk of
C

asthma-related mortality, exacerbations, persistent airflow limitation and side-effects of treatment. The patient’s
T
O

own goals for their asthma and its treatment should also be identified.
N
O

The patient-health professional partnership

-D

• Effective asthma management requires a partnership between the person with asthma (or the parent/caregiver)
L
IA

and their health care providers.

ER

• Teaching communication skills to health care providers may lead to increased patient satisfaction, better health
AT

outcomes, and reduced use of healthcare resources.

M

The patient’s ‘health literacy’ – that is, the patient’s ability to obtain, process and understand basic health
D

•
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information to make appropriate health decisions – should be taken into account.

H
IG

Making decisions about asthma treatment

R

• Asthma treatment is adjusted in a continual cycle of assessment, treatment, and review of the patient’s response
PY

in both symptom control and future risk (of exacerbations and side-effects), and of patient preferences.
O
C

• For population-level decisions about asthma medications, e.g., choices made by national guidelines, insurers,
health maintenance organizations or national formularies, the ‘preferred’ regimens in Steps 1–4 represent the
best treatments for most patients, based on evidence from randomized controlled trials, meta-analyses and
observational studies about safety, efficacy and effectiveness, with a particular emphasis on symptom burden
and exacerbation risk. For Steps 1–5, there are different preferred population-level recommendations for different
age-groups (adults/adolescents, children 6–11 years, children 5 years and younger). In Step 5, there are also
different preferred population-level recommendations depending on the inflammatory phenotype, Type 2 or non-
Type 2.
• For individual patients, shared decision-making about treatment should also take into account any patient
characteristics or phenotype that predict the patient’s risk of exacerbations or other adverse outcomes, or their
likely response to treatment, together with the patient’s goals or concerns and practical issues (inhaler technique,
adherence, medication access and cost to the patient).

48 3. Treating to control symptoms and minimize future risk

LONG-TERM GOALS OF ASTHMA MANAGEMENT
The long-term goals of asthma management from a clinical perspective are:
• To achieve good control of symptoms and maintain normal activity levels
• To minimize the risk of asthma-related death, exacerbations, persistent airflow limitation and side-effects.
It is also important to elicit the patient’s own goals regarding their asthma, as these may differ from conventional medical
goals. Shared goals for asthma management can be achieved in various ways, taking into account differing health care
systems, medication availability, and cultural and personal preferences.

THE PATIENT-HEALTH CARE PROVIDER PARTNERSHIP

Effective asthma management requires the development of a partnership between the person with asthma (or the
parent/caregiver) and health care providers.176 This should enable the person with asthma to gain the knowledge,
confidence and skills to assume a major role in the management of their asthma. Self-management education reduces
asthma morbidity in both adults177 (Evidence A) and children178 (Evidence A).

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There is emerging evidence that shared decision-making is associated with improved outcomes.179 Patients should be

IB
encouraged to participate in decisions about their treatment, and given the opportunity to express their expectations and

TR
concerns. This partnership needs to be individualized for each patient. A person’s willingness and ability to engage in

IS
self-management may vary depending on factors such as ethnicity, literacy, understanding of health concepts (health

D
R
literacy), numeracy, beliefs about asthma and medications, desire for autonomy, and the health care system.

O
Good communication
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O
C
Good communication by health care providers is essential as the basis for good outcomes180-182 (Evidence B). Teaching
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O

healthcare providers to improve their communication skills (Box 3-1) can result in increased patient satisfaction, better
N

health outcomes, and reduced use of health care resources180-182 without lengthening consultation times.183 It can also
O
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enhance patient adherence.183 Training patients to give information clearly, seek information, and check their
understanding of information provided is also associated with improved adherence with treatment recommendations.183
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Box 3-1. Communication strategies for health care providers

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Key strategies to facilitate good communication181,182

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• A congenial demeanor (friendliness, humor and attentiveness)

H
IG

• Allowing the patient to express their goals, beliefs and concerns

R

• Empathy, reassurance, and prompt handling of any concerns

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• Giving encouragement and praise

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C

• Giving appropriate (personalized) information

• Providing feedback and review
How to reduce the impact of low health literacy184

• Order information from most to least important.

• Speak slowly and use simple words (avoid medical language, if possible).
• Simplify numeric concepts (e.g., use numbers instead of percentages).
• Frame instructions effectively (use illustrative anecdotes, drawings, pictures, table or graphs).
• Confirm understanding by using the ‘teach-back’ method (ask patients to repeat instructions).
• Ask a second person (e.g., nurse, family member) to repeat the main messages.
• Pay attention to non-verbal communication by the patient.
• Make patients feel comfortable about asking questions.

3. Treating to control symptoms and minimize future risk 49

Health literacy and asthma
There is increasing recognition of the impact of low health literacy on health outcomes, including in asthma.184,185 Health
literacy means much more than the ability to read: it is defined as ‘the degree to which individuals have the capacity to
obtain, process and understand basic health information and services to make appropriate health decisions’.184 Low
health literacy is associated with reduced knowledge and worse asthma control.186 In one study, low numeracy among
parents of children with asthma was associated with higher risk of exacerbations.185 Interventions adapted for cultural
and ethnicity perspectives have been associated with improved knowledge and significant improvements in inhaler
technique.187 Suggested communication strategies for reducing the impact of low health literacy are shown in Box 3-1.

PERSONALIZED CONTROL-BASED ASTHMA MANAGEMENT

Asthma control has two domains: symptom control and risk reduction (see Box 2-2, p.38). In control-based asthma
management, pharmacological and non-pharmacological treatment is adjusted in a continual cycle that involves
assessment, treatment and review by appropriately trained personnel (Box 3-2) in order to achieve the goals of asthma

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treatment (p.49). Asthma outcomes have been shown to improve after the introduction of control-based guidelines188,189

U
or practical tools for implementation of control-based management strategies.179,190

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Box 3-2. The asthma management cycle for personalized asthma care

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Personalized asthma management involves a continual cycle of assessment, adjustment of treatment and review.
• ASSESS the patient’s symptom control and their risk factors for exacerbations, for decline in lung function and for
medication adverse effects (Box 2-2, p.38), with particular attention to inhaler technique and adherence. Assess
comorbidities and the patient’s goals and preferences, and confirm the diagnosis of asthma if not yet done.
• ADJUST the patient’s management, based on these assessments. This includes treatment of modifiable risk
factors (Box 3-17, p.85) and comorbidities (p.106), relevant non-pharmacologic strategies (Box 3-18, p.88),
education and skills training (Chapter 3.3, p.98), and adjustment of medication as required (Chapter 3.2, p.53). For
adults and adolescents, the preferred controller and reliever treatment across all steps is with combination
ICS-formoterol, as shown in GINA Track 1 (Box 3-12, p.65).
• REVIEW the patient in line with the goals of treatment (p.49), reassess factors affecting symptoms, risk of adverse
outcomes and patient satisfaction, arrange further investigations if needed, and readjust treatment if needed.
See list of abbreviations (p.10).

50 3. Treating to control symptoms and minimize future risk

 The concept of control-based management is also supported by the design of most randomized controlled medication
trials, in which patients are identified for a change in asthma treatment on the basis of features of poor symptom control
with or without other risk factors such as low lung function or a history of exacerbations. From 2014, GINA asthma
management has focused not only on asthma symptom control, but also on personalized management of the patient’s
modifiable risk factors for exacerbations, other adverse outcomes and multimorbidity, and also taking into account the
patient’s preferences and goals.
For many patients in primary care, achieving good symptom control is a good guide to a reduced risk of
exacerbations.191 When inhaled corticosteroids (ICS) were introduced into asthma management, large improvements
were observed in symptom control and lung function, and exacerbations and asthma-related mortality also decreased.
However, patients with apparently mild asthma and few or intermittent symptoms may be still at risk of severe
exacerbations166 (Box 2-2B, p.38). In addition, some patients continue to have exacerbations despite well-controlled
symptoms, and for patients with ongoing symptoms, side-effects may be an issue if ICS doses continue to be stepped
up. Therefore, in control-based management, both domains of asthma control (symptom control and future risk – see

TE
Box 2-2, p.38) should be taken into account when choosing asthma treatment and reviewing the response.29,69

U
IB
Choosing between asthma treatment options

TR
IS
At each treatment step in asthma management, different medication options are available that, although not of identical

D
efficacy, may be alternatives for controlling asthma. Different considerations apply to recommendations or choices made

R
O
for broad populations compared with those for individual patients (Box 3-3, p.52), as follows:

PY
• Population-level medication choices: Population-level medication choices are often applied by bodies such as
O
national formularies or managed care organizations. Population-level recommendations aim to represent the best
C
T

option for most patients in the particular population. At each treatment step, ‘preferred’ controller and reliever
O

regimens are recommended that provide the best benefit-to-risk ratio for both symptom control and risk reduction.
N
O

Choice of the preferred controller and/or preferred reliever is based on evidence from efficacy studies (highly
-D

controlled studies in well-characterized populations) and effectiveness studies (from pragmatically controlled
L

studies, or studies in broader populations, or strong observational data),192 with a particular focus on symptoms
IA
ER

and exacerbation risk. Safety and relative cost are also considered. In Step 5, there are different population-level
AT

recommendations depending on the inflammatory phenotype, Type 2 or non-Type 2.

M

In the treatment figure for adults and adolescents (Box 3-12, p.65), the options are shown in two ‘tracks’. Track 1,
D

with as-needed low-dose ICS-formoterol as the reliever, is the preferred approach for most patients, based on
TE

evidence of overall lower exacerbation risk and similar symptom control, and a simpler regimen for stepping
H
IG

treatment up and down as needed, compared with treatments in Track 2 in which the reliever is short-acting beta2
R

agonist (SABA) or, in some cases, combination ICS-SABA (for more details, see Chapter 3.2, p.53).
PY

• Patient-level medication choices: Treatment choices for individual patients also take into account any patient
O
C

characteristics or phenotype that may predict their risk of exacerbations or other adverse outcomes, or a clinically
important difference in their response compared with other patients, together with assessment of multimorbidity,
the patient’s goals and preferences, and practical issues such as cost, ability to use the medication and
adherence (see Box 3-2, p.50). For factors relating to the choice of inhaler, see Chapter 3.3 (p.98).
The extent to which asthma treatment can be individualized according to patient characteristics or phenotypes depends
on the health system, the clinical context, the potential magnitude of difference in outcomes, cost and available
resources. At present, most evidence and research activity about individualized treatment is focused on severe
asthma193,194 (see Chapter 3.5, p.120).

3. Treating to control symptoms and minimize future risk 51

 Box 3-3. Population level versus patient level decisions about asthma treatment

Choosing between treatment options at a population level

(e.g. national formularies, health maintenance organizations, national guidelines)

The ‘preferred’ medication at each step is the best treatment for most patients, based on:
• Efficacy
• Effectiveness Mainly based on evidence about symptoms and exacerbations (from
randomized controlled trials, pragmatic studies and strong observational data)
• Safety
• Availability and cost at the population level
For Steps 1–5, there are different population-level recommendations by age-group (adults/adolescents,
children 6–11 years, children 5 years and younger). In Step 5, there are also different population-level

TE
recommendations depending on the inflammatory phenotype, Type 2 or non-Type 2.

U
IB
Choosing between controller options for individual patients

TR
IS
Use shared decision-making with the patient or parent/caregiver to discuss the following:

D
R
1. Preferred treatment (as above) based on evidence for symptom control and risk reduction

O
PY
2. Patient characteristics or phenotype O
• Does the patient have any features that predict differences in their future risk or treatment
C
T

response compared with other patients (e.g., smoker; history of exacerbations, blood
O
N

eosinophilia)? (see Box 2-2B, p.38)

O

• Are there any modifiable risk factors or multimorbidity that may affect treatment outcomes?
-D
L

3. Patient views
IA
ER

• What are the patient’s goals, beliefs and concerns about asthma and medications?
AT

4. Practical issues
M

For the preferred controller and reliever, which inhaler(s) are available to the patient?
D

•
TE

• Inhaler technique – can the patient use the inhaler correctly after training?
H
IG

• Adherence – how often is the patient likely to take the medication?

R
PY

• Cost to patient – can the patient afford the medication?

O

• Which of the available inhalers has the lowest environmental impact? (see p.98)
C

52 3. Treating to control symptoms and minimize future risk

 3.2. MEDICATIONS AND STRATEGIES FOR SYMPTOM CONTROL AND RISK REDUCTION

KEY POINTS

• For safety, GINA does not recommend treatment of asthma in adults, adolescents or children 6–11 years with
SABA alone. Instead, they should receive ICS-containing treatment to reduce their risk of serious exacerbations
and to control symptoms.
• ICS-containing treatment can be delivered either with regular daily treatment or, in adults and adolescents with mild
asthma, with as-needed low-dose ICS-formoterol taken whenever needed for symptom relief. For children with mild
asthma, ICS can be taken whenever the SABA reliever is taken.
• Reduction in severe exacerbations is a high priority across treatment steps, to reduce the risk and burden to
patients and the burden to the health system, and to reduce the need for oral corticosteroids (OCS), which have
cumulative long-term adverse effects.
Treatment tracks for adults and adolescents

TE
• For clarity, the treatment figure for adults and adolescents shows two ‘tracks’, largely based on the choice of reliever.

U
Treatment may be stepped up or down within a track using the same reliever at each step, or treatment may be

IB
switched between tracks, according to the individual patient’s needs.

TR
IS
• Track 1, in which the reliever is low-dose ICS-formoterol, is the preferred approach recommended by GINA. When a

D
patient at any step has asthma symptoms, they use low-dose ICS-formoterol as needed for symptom relief. In

R
O
Steps 3–5, they also take ICS-formoterol as regular daily treatment. This approach is preferred because it reduces

PY
the risk of severe exacerbations compared with using a SABA reliever, with similar symptom control, and because of
O
the simplicity for patients and clinicians of needing only a single medication across treatment steps 1–4. Medications
C

and doses for Track 1 are explained in Box 3-15, p.80.

T
O
N

• Track 2, in which the reliever is a SABA or ICS-SABA, is an alternative if Track 1 is not possible, or if a patient is
O

stable, with good adherence and no exacerbations in the past year on their current therapy. In Step 1, the patient
-D

takes a SABA and a low-dose ICS together for symptom relief (in combination if available, or with the ICS taken
L

immediately after the SABA). In Steps 2–5, the reliever is a SABA or combination ICS-SABA. Before considering a
IA
ER

SABA reliever, consider whether the patient is likely to be adherent with their ICS-containing treatment, as otherwise
AT

they would be at higher risk of exacerbations.

M

Steps 1 and 2
D
TE

• Track 1: In adults and adolescents with mild asthma or who are taking SABA alone, treatment with as-needed-only
H

low-dose ICS-formoterol reduces the risk of severe exacerbations and emergency department visits or
IG

hospitalizations by about two-thirds compared with SABA-only treatment. As-needed-only low-dose ICS-formoterol
R
PY

reduces the risk of emergency department visits and hospitalizations compared with daily ICS, with no clinically
O

important difference in symptom control. In patients previously using SABA alone, as-needed low-dose ICS-
C

formoterol also significantly reduces the risk of severe exacerbations needing OCS, compared with daily ICS.
• Track 2: Treatment with regular daily low-dose ICS plus as-needed SABA is highly effective in reducing asthma
symptoms and reducing the risk of asthma-related exacerbations, hospitalization and death. However, adherence
with ICS in the community is poor, leaving patients taking SABA alone and at increased risk of exacerbations. While
as-needed-only ICS-SABA could be an option at this step, current evidence is limited to small studies that were not
powered to detect differences in exacerbation rates.
(continued on next page)

3. Treating to control symptoms and minimize future risk 53

KEY POINTS (continued)

Stepping up if asthma remains uncontrolled despite good adherence and inhaler technique
• Before considering any step up, first confirm that the symptoms are due to asthma and identify and address common
problems such as inhaler technique, adherence, allergen exposure and multimorbidity; provide patient education.
• For adults and adolescents, the preferred Step 3 treatment is the Track 1 regimen with low-dose ICS-formoterol as
maintenance-and-reliever therapy (MART). This reduces the risk of severe exacerbations, with similar or better
symptom control, compared with maintenance treatment using a combination of an ICS and a long-acting beta2
agonist (LABA) as controller, plus as-needed SABA. If needed, the maintenance dose of ICS-formoterol can be
increased to medium (i.e. Step 4) by increasing the number of maintenance inhalations. MART is also a preferred
treatment option at Steps 3 and 4 for children 6–11 years, with a lower dose ICS-formoterol inhaler.
• ICS-formoterol should not be used as the reliever for patients taking a different ICS-LABA maintenance treatment,
because clinical evidence for safety and efficacy is lacking.

• Other Step 3 options for adults and adolescents in Track 2, and in children, include maintenance ICS-LABA plus as-

TE
needed SABA or plus as-needed ICS-SABA (if available) or, for children 6–11 years, medium-dose ICS plus as-

U
needed SABA.

IB
TR
• For children, try other controller options at the same step before stepping up.

IS
Stepping down to find the minimum effective dose

D
R
• Once good asthma control has been achieved and maintained for 2–3 months, consider stepping down gradually to

O
find the patient’s lowest treatment that controls both symptoms and exacerbations
PY
O
• Provide the patient with a written asthma action plan, monitor closely, and schedule a follow-up visit.
C
T

• Do not completely withdraw ICS unless this is needed temporarily to confirm the diagnosis of asthma.
O
N

For all patients with asthma, providing asthma education and training in essential skills
O
-D

• After choosing the right class of medication for the patient, the choice of inhaler device depends on which inhalers
L

are available for the patient for that medication, which of these inhalers the patient can use correctly after training,
IA

and their relative environmental impact. Check inhaler technique frequently.

ER
AT

• Provide inhaler skills training: this is essential for medications to be effective, but technique is often incorrect.
M

• Encourage adherence with controller medication, even when symptoms are infrequent.
D
TE

• Provide training in asthma self-management (self-monitoring of symptoms and/or peak expiratory flow (PEF), written
H

asthma action plan and regular medical review) to control symptoms and minimize the risk of exacerbations.
IG
R

For patients with one or more risk factors for exacerbations

PY

• Prescribe ICS-containing medication, preferably from Track 1 options, i.e., with as-needed low-dose ICS-formoterol
O
C

as reliever; provide a written asthma action plan; and arrange review more frequently than for lower-risk patients.
• Identify and address modifiable risk factors (e.g., smoking, low lung function, over-use of SABA).
• Consider non-pharmacological strategies and interventions to assist with symptom control and risk reduction,
(e.g., smoking cessation advice, breathing exercises, some avoidance strategies).
Difficult-to-treat and severe asthma (see section 3.5, p.120)
• Patients who have poor symptom control and/or exacerbations, despite medium- or high-dose ICS-LABA treatment,
should be assessed for contributing factors, and asthma treatment optimized.
• If the problems continue or diagnosis is uncertain, refer to a specialist center for phenotypic assessment and
consideration of add-on therapy including biologics.
For all patients, use your own professional judgment, and always check local eligibility and payer criteria

54 3. Treating to control symptoms and minimize future risk

ASTHMA MEDICATIONS

Categories of asthma medications

The pharmacological options for long-term treatment of asthma fall into the following main categories (Box 3-4; p.56):
• Controller medications: in the past, this term mostly referred to medications containing ICS that were used to
reduce airway inflammation, control symptoms, and reduce risks such as exacerbations and related decline in
lung function.127 In GINA Track 1, controller treatment is delivered through an anti-inflammatory reliever (AIR),
low-dose ICS-formoterol, taken when symptoms occur and before exercise or allergen exposure; in Steps 3–5, the
patient also takes maintenance controller treatment (daily or twice-daily ICS-formoterol). This is called
maintenance-and-reliever therapy (MART). The dose and regimen of controller medications should be optimized
to minimize the risk of medication side-effects, including risks of needing OCS.

• Reliever medications: these are provided to all patients for as-needed relief of breakthrough symptoms, including
during worsening asthma or exacerbations. They are also recommended for short-term prevention of exercise-
induced bronchoconstriction (EIB). Relievers include the anti-inflammatory relievers ICS-formoterol and ICS-

TE
SABA, and SABA alone. Over-use of SABA (e.g., dispensing of three or more 200-dose canisters in a year,

U
corresponding to average use more than daily) increases the risk of asthma exacerbations.74,75

IB
TR
• Add-on therapies including for patients with severe asthma (Section 3.5, p.120).

IS
D
When compared with medications used for other chronic diseases, most of the medications used for treatment of

R
asthma have very favorable therapeutic ratios.

O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

3. Treating to control symptoms and minimize future risk 55

 Box 3-4. Terminology for asthma medications
Term Definition
Maintenance Asthma treatment that is
treatment prescribed for use every
day (or on a regularly
scheduled basis)
Controller Medication targeting both
domains of asthma control
(symptom control and
future risk)
Reliever Asthma inhaler taken as
needed, for quick relief of
asthma symptoms
Anti-inflammatory Reliever inhaler that
IA
reliever (AIR) contains both a low-dose
ER
ICS and a rapid-acting
AT
bronchodilator
M
D
TE
H
IG
R
PY
O
C
Maintenance-and- Treatment regimen in
reliever therapy which the patient uses an
(MART) ICS-formoterol inhaler
every day (maintenance
dose), and also uses the
same medication as
needed for relief of asthma
symptoms (reliever doses)
See list of abbreviations (p.10).
56
Notes
Medications intended to be used continuously, even when the person
does not have asthma symptoms. Examples include ICS-containing
medications (ICS, ICS-LABA, ICS-LABA-LAMA), as well as LTRA
and biologic therapy.
The term ‘maintenance’ describes the prescribed frequency of
administration, not a particular class of asthma medicine.
In the past, ‘controller’ was largely used for ICS-containing
medications prescribed for regular daily treatment, so ‘controller’ and
‘maintenance’ became almost synonymous. However, this became
confusing after the introduction of combination ICS-containing
relievers for as-needed use.
TE
To avoid confusion, ‘ICS-containing treatment’ and ‘maintenance
U
treatment’ have been substituted as appropriate where the intended
IB
meaning was unclear.
TR
IS
Sometimes called rescue inhalers. As well as being used for
D
symptom relief, reliever inhalers can also be used before exercise, to
R
prevent exercise-induced asthma symptoms.
O
PY
Includes SABAs (e.g., salbutamol [albuterol], terbutaline, ICS-
O
salbutamol), as-needed ICS-formoterol, and as-needed ICS-SABA.
C
T
SABA-containing relievers are not intended for regular maintenance
O
N
use, or to be taken when the person does not have asthma
O
symptoms (except before exercise).
-D
Includes budesonide-formoterol, beclometasone-formoterol and
L
ICS-salbutamol combinations. Patients can also use them as needed
before exercise or allergen exposure to prevent asthma symptoms
and bronchoconstriction. Non-formoterol LABAs in combination with
ICS cannot be used as relievers.
The anti-inflammatory effect of as-needed ICS-formoterol was
demonstrated by reduction in FeNO in several studies.171,172,195
Some anti-inflammatory relievers can be used as-needed at Steps
1–2 as the person’s sole asthma treatment, without a maintenance
treatment (‘AIR-only’ treatment). Almost all evidence for this is with
ICS-formoterol. Some ICS-formoterol combinations can be used as
both maintenance treatment and reliever treatment at Steps 3–5 (see
MART, below). For medications and doses see Box 3-15, p.80.
MART (Maintenance And Reliever Therapy) can be used only with
combination ICS-formoterol inhalers such as budesonide-formoterol
and beclometasone-formoterol. Other ICS-formoterol inhalers can
also potentially be used, but combinations of ICS with non-formoterol
LABAs, or ICS-SABA, cannot be used for MART. MART is also
sometimes called SMART (single-inhaler maintenance and reliever
therapy); the meaning is the same. For medications and doses see
Box 3-15, p.80.
3. Treating to control symptoms and minimize future risk
Initial asthma treatment in adults, adolescents and children 6–11 years
For the best outcomes, ICS-containing treatment should be initiated when (or as soon as possible after) the diagnosis of
asthma is made. All patients should also be provided with a reliever inhaler for quick symptom relief, preferably an anti-
inflammatory reliever (AIR).
Why should ICS-containing medication be commenced from the time of diagnosis?
• As-needed low-dose ICS-formoterol reduces the risk of severe exacerbations and emergency department visits or
hospitalizations by 65% compared with SABA-only treatment.167 This anti-inflammatory reliever regimen (AIR-only)
significantly reduces severe exacerbations regardless of the patient’s baseline symptom frequency, lung function,
exacerbation history or inflammatory profile (T2-high or T2-low).171,172
• Starting treatment with SABA alone trains patients to regard it as their main asthma treatment, and increases the
risk of poor adherence when daily ICS is subsequently prescribed.
• Early initiation of low-dose ICS in patients with asthma leads to a greater improvement in lung function than if
symptoms have been present for more than 2–4 years.196,197 One study showed that after this time, higher ICS
doses were required, and lower lung function was achieved.198

TE
• Patients not taking ICS who experience a severe exacerbation have a greater long-term decline in lung function

U
IB
than those who are taking ICS.127

TR
• For patients with occupational asthma, early removal from exposure to the sensitizing agent and early ICS-

IS
containing treatment increase the probability of resolution of symptoms, and improvement of lung function and

D
airway hyperresponsiveness.49,50

R
O
For adults and adolescents, recommended options for initial asthma treatment, based on evidence (where available) and
PY
consensus, are listed in Box 3-6 (p.59) and shown in Boxes 3-7 (p.60) and 3-8 (p.60). Treatment for adults and
O
C
adolescents is shown in two tracks, depending on the reliever inhaler (Box 3-12, p.65).
T
O

For children 6–11 years, recommendations about initial treatment are on p.62 and p.63. The patient’s response should
N
O

be reviewed, and treatment stepped down once good control is achieved. Recommendations for a stepwise approach to
-D

ongoing treatment are found in Box 3-13 (p.66).

L
IA

Does FeNO help in deciding whether to commence ICS?

ER

In studies mainly limited to non-smoking adult patients, fractional concentration of exhaled nitric oxide (FeNO) >50 parts
AT

per billion (ppb) was associated with a good short-term (weeks) response to ICS.199,200 However, these studies did not
M
D

examine the longer-term risk of exacerbations. In two 12-month studies in mild asthma or taking SABA alone, severe
TE

exacerbations were reduced with as-needed low-dose ICS-formoterol versus as-needed SABA and versus maintenance
H

ICS, independent of baseline inflammatory characteristics including FeNO.171,172

IG
R

Consequently, in patients with a diagnosis or suspected diagnosis of asthma, measurement of FeNO can support the
PY

decision to start ICS, but cannot be used to decide against treatment with ICS. Based on past and current evidence,
O
C

GINA recommends treatment with daily low-dose ICS or as-needed low-dose ICS-formoterol for all adults and
adolescents with mild asthma, to reduce the risk of serious exacerbations.171,172,201-203

Adjusting ongoing asthma treatment in adults, adolescents and children 6–11 years old
Once asthma treatment has been commenced (Boxes 3-6 to 3-10), ongoing treatment decisions are based on a
personalized cycle of assessment, adjustment of treatment, and review of the response. For each patient, in addition to
treatment of modifiable risk factors, asthma medication can be adjusted up or down in a stepwise approach (adults and
adolescents: Box 3-12, p.65, children 6–11 years, Box 3-13, p.66) to achieve good symptom control and minimize future
risk of exacerbations, persistent airflow limitation and medication side-effects. Once good asthma control has been
maintained for 2–3 months, treatment may be stepped down in order to find the patient’s minimum effective treatment
(Box 3-16, p.83).

3. Treating to control symptoms and minimize future risk 57

 People’s ethnic and racial backgrounds may be associated with different responses to treatment. These are not
necessarily associated with genetic differences.204 The contributors are likely to be multifactorial, including differences in
exposures, social disadvantage, diet and health-seeking behavior.
If a patient has persisting uncontrolled symptoms and/or exacerbations despite 2–3 months of ICS-containing treatment,
assess and correct the following common problems before considering any step up in treatment:
• Incorrect inhaler technique
• Poor adherence
• Persistent exposure at home/work to agents such as allergens, tobacco smoke, indoor or outdoor air pollution, or
to medications such as beta-blockers or (in some patients) nonsteroidal anti-inflammatory drugs (NSAIDs)
• Comorbidities that may contribute to respiratory symptoms and poor quality of life
• Incorrect diagnosis.

Box 3-5. Asthma treatment tracks for adults and adolescents

For adults and adolescents, the main treatment figure (Box 3-12, p.65), shows the options for ongoing treatment as two

TE
treatment ‘tracks’, with the key difference being the medication that is used for symptom relief. In Track 1 (preferred), the

U
reliever is as-needed low-dose ICS-formoterol, and in Track 2, the reliever is as-needed SABA or as-needed ICS-SABA.

IB
TR
The two tracks show how treatment can be stepped up and down using the same reliever at each step.

IS
Track 1: The reliever is as-needed low-dose ICS-formoterol

D
R
O
This is the preferred approach recommended by GINA for adults and adolescents, because of the extensive evidence

PY
that using low-dose ICS-formoterol (an anti-inflammatory reliever; AIR) reduces the risk of severe exacerbations
O
compared with using SABA as reliever, with similar symptom control. In addition, the treatment regimen is simpler, with
C

patients using a single medication for reliever and for maintenance treatment if prescribed, across treatment steps.
T
O

o With this approach, when a patient at any treatment step has asthma symptoms, they use low-dose
N
O

ICS-formoterol in a single inhaler for symptom relief and to provide anti-inflammatory therapy.
-D

o In Steps 3–5, patients also take ICS-formoterol as their daily maintenance treatment; together, this is called
L
IA

‘maintenance-and-reliever therapy’ (MART).

ER

o Medications and doses for GINA Track 1 are shown in Box 3-15, p.80.
AT

Track 2: The reliever is as-needed SABA or as-needed ICS-SABA

M
D
TE

This is an alternative approach if Track 1 is not possible, or if a patient’s asthma is stable with good adherence and no
H

exacerbations on their current therapy. However, before prescribing a regimen with SABA-only reliever, consider if the
IG

patient is likely to be adherent with their maintenance therapy, as otherwise they will be at higher risk of exacerbations.
R
PY

• In Step 1, the patient takes a SABA and a low-dose ICS together for symptom relief when symptoms occur (in a
O

combination inhaler, or with the ICS taken immediately after the SABA).
C

• In Steps 2–5, a SABA or combination ICS-SABA is used for symptom relief, and the patient takes maintenance ICS-
containing medication regularly every day. If the reliever and maintenance medication are in different devices, make
sure that the patient can use each inhaler correctly.

Stepping up and down

Treatment can be stepped up or down along one track, using the same reliever at each step, or it can be switched
between tracks, according to the individual patient’s needs and preferences. Before stepping up, check for common
problems such as incorrect inhaler technique, poor adherence, and environmental exposures, and confirm that the
symptoms are due to asthma (Box 2-4, p.45).

The additional controller options, shown below the two treatment tracks, either have limited indications or less evidence
for their safety and/or efficacy, compared with the treatments in Tracks 1 and 2.
See list of abbreviations (p.10).

58 3. Treating to control symptoms and minimize future risk

 Box 3-6. Initial asthma treatment - recommended options for adults and adolescents

Presenting symptoms Preferred INITIAL treatment Alternative INITIAL treatment

(Track 1) (Track 2)

Infrequent asthma symptoms,
e.g., less than twice a month and
no risk factors for exacerbations,
including no exacerbations in the
last 12 months (Box 2-2B, p.38)
As-needed low-dose ICS- Low-dose ICS taken whenever SABA is
formoterol (Evidence B) taken, in combination or separate inhalers
(Evidence B)

Asthma symptoms or need for As-needed low-dose ICS- Low-dose ICS plus as-needed SABA
reliever twice a month or more formoterol (Evidence A) (Evidence A). Before choosing this option,
consider likely adherence with daily ICS.

Troublesome asthma symptoms Low-dose ICS-formoterol Low-dose ICS-LABA plus as-needed SABA

TE
most days (e.g., 4–5 days/week); maintenance and reliever (Evidence A) or plus as-needed ICS-SABA

U
or waking due to asthma once a therapy (MART) (Evidence A) (Evidence B), OR

IB
week or more, especially if any Medium-dose ICS plus as-needed SABA

TR
risk factors exist (Box 2-2B, p.38) (Evidence A) or plus as-needed ICS-SABA

IS
D
(Evidence B).

R
Consider likely adherence with daily

O
PY
maintenance treatment.
O
C
Initial asthma presentation is with Medium-dose ICS-formoterol Medium- or high-dose ICS-LABA (Evidence D)
T

severely uncontrolled asthma, or maintenance and reliever plus as-needed SABA or plus as-needed
O
N

with an acute exacerbation therapy (MART) (Evidence D). ICS-SABA. Consider likely adherence with
O

A short course of oral daily maintenance treatment. A short course of

-D

corticosteroids may also be oral corticosteroids may also be needed.

L
IA

needed. High-dose ICS plus as-needed SABA is another

ER

option (Evidence A) but adherence is weak

AT

compared with combination ICS-LABA.

M

Before starting initial controller treatment

D
TE
H

• Record evidence for the diagnosis of asthma.

IG

Record the patient’s level of symptom control and risk factors, including lung function (Box 2-2, p.38).
R

•
PY

• Consider factors influencing choice between available treatment options (Box 3-3, p.52), including likely
O

adherence with daily ICS-containing treatment, particularly if the reliever is SABA.

C

• Choose a suitable inhaler (Box 3-21 p.98) and ensure that the patient can use the inhaler correctly.
• Schedule an appointment for a follow-up visit.

After starting initial controller treatment

• Review patient’s response (Box 2-2, p.38) after 2–3 months, or earlier depending on clinical urgency.
• See Box 3-12 (p.65) for recommendations for ongoing treatment and other key management issues.
• Check adherence and inhaler technique frequently.
• Step down treatment once good control has been maintained for 3 months (Box 3-16, p.83).
This table is based on evidence from available studies and consensus. Considerations also include cost and likely adherence with ICS-containing
treatment. See also Box 3-7 (p.60) for where to start on the main treatment figure for adults and adolescents. See Box 3-14, p.67 for low, medium and
high ICS doses for adults and adolescents, and Box 3-15 (p.80) for Track 1 medications and doses. See list of abbreviations (p.10).

3. Treating to control symptoms and minimize future risk 59

 Box 3-7. Selecting initial treatment in adults and adolescents with a diagnosis of asthma

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10). See Box 3-14, p.67 for low, medium and high ICS doses for adults and adolescents. See Box 3-15, p.80, for Track 1 medications and doses.

60 3. Treating to control symptoms and minimize future risk

 Box 3-8. Flowchart for selecting initial treatment in adults and adolescents with a diagnosis of asthma

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10). See Box 3-14, p.67 for low, medium and high ICS doses for adults and adolescents. See Box 3-15, p.80, for Track 1 medications and doses.

3. Treating to control symptoms and minimize future risk 61

 Box 3-9. Initial asthma treatment – recommended options for children aged 6–11 years
Presenting symptoms Preferred INITIAL treatment

Infrequent asthma symptoms, Low-dose ICS taken whenever SABA is taken (Evidence B)
e.g., less than twice a month and no in combination or separate inhalers
risk factors for exacerbations (Box An alternative option is daily maintenance low-dose ICS with as-needed
2-2B, p.38) SABA (Evidence B).

Asthma symptoms or need for reliever
twice a month or more, but less than
daily
Low-dose ICS plus as-needed SABA (Evidence A)
Other options include daily LTRA (less effective than ICS, Evidence A), or
taking ICS whenever SABA is taken in combination or separate inhalers
(Evidence B). Consider likely adherence with maintenance treatment if
reliever is SABA.

Troublesome asthma symptoms most Low-dose ICS-LABA plus as needed SABA (Evidence A), OR

TE
days (e.g., 4–5 days/week); or waking

U
Medium-dose ICS plus as-needed SABA (Evidence A), OR

IB
due to asthma once a week or more,
Very-low-dose ICS-formoterol maintenance and reliever (Evidence B)

TR
especially if any risk factors exist (Box

IS
2-2B) Other options include daily low-dose ICS and LTRA, plus as-needed SABA.

D
R
O
Initial asthma presentation is with Start regular maintenance treatment with medium-dose ICS-LABA plus

PY
severely uncontrolled asthma, or with as-needed SABA or low-dose ICS-formoterol maintenance and reliever
O
an acute exacerbation (MART). A short course of OCS may also be needed.
C
T

Before starting initial controller treatment

O
N
O

• Record evidence for the diagnosis of asthma, if possible.

-D

• Record the child’s level of symptom control and risk factors, including lung function (Box 2-2, p.38, Box 2-3, p.39).
L
IA

• Consider factors influencing choice between available treatment options (Box 3-3, p.52).
ER

• Choose a suitable inhaler (Box 3-21 p.98) and ensure that the child can use the inhaler correctly.
AT
M

• Schedule an appointment for a follow-up visit.

D
TE

After starting initial controller treatment

H
IG

• Review child’s response (Box 2-2, p.38) after 2–3 months, or earlier depending on clinical urgency.
R
PY

• See Box 3-13 (p.66) for recommendations for ongoing treatment and other key management issues.
O

• Step down treatment once good control has been maintained for 3 months (Box 3-16, p.83).
C

This table is based on evidence from available studies and from consensus, including considerations of cost. See also Box 3-4D (p.63) for where to
start on the main treatment figure for children 6–11 years. See Box 3-14, p.67 for low, medium and high ICS doses in children, and Box 3-15 (p.80) for
MART doses in children.. See list of abbreviations (p.10).

62 3. Treating to control symptoms and minimize future risk

 Box 3-10. Selecting initial treatment in children aged 6–11 years with a diagnosis of asthma

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10). See Box 3-14, p.67 for low, medium and high ICS doses in children. See Box 3-15, p.80 for medications and doses for MART in children.

3. Treating to control symptoms and minimize future risk 63

 Box 3-11. Flowchart for selecting initial treatment in children aged 6–11 years with a diagnosis of asthma

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10). See Box 3-14, p.67 for low, medium and high ICS doses in children. See Box 3-15, p.80 for medications and doses for MART in children.

64 3. Treating to control symptoms and minimize future risk

Box 3-12. Personalized management for adults and adolescents to control symptoms and minimize future risk

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10). For recommendations about initial asthma treatment in adults and adolescents, see Box 3-7 (p.59) and 3-8 (p.60). See Box 3-14, p.67 for low, medium and high ICS
doses for adults and adolescents. See Box 3-15, p.80, for Track 1 medications and doses.

3. Treating to control symptoms and minimize future risk 65

Box 3-13. Personalized management for children 6–11 years to control symptoms and minimize future risk

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10). For initial asthma treatment in children aged 6–11 years, see Box 3-4C (p.62) and Box 3-4D (p.63) See Box 3-14, p.67 for low, medium and high
ICS doses in children. See Box 3-15 for MART doses for children 6–11 years.
66 3. Treating to control symptoms and minimize future risk
 Box 3-14. Low, medium and high daily metered doses of inhaled corticosteroids (alone or with LABA)

This is not a table of equivalence, but instead, suggested total daily doses for ‘low’, ‘medium’ and ‘high’ dose ICS
options for adults/adolescents (Box 3-12, p.65) and children 6–11 years (Box 3-13, p.66), based on product
information. Few data are available for comparative potency, and this table does NOT imply potency equivalence.
Doses may differ by country, depending on local products, regulatory labelling and clinical guidelines or, for one
product, with addition of a LAMA to an ICS-LABA.205
Low-dose ICS provides most of the clinical benefit of ICS for most patients with asthma. However, ICS responsiveness
varies between patients, so some patients may need medium-dose ICS if their asthma is uncontrolled, or they have
ongoing exacerbations, despite good adherence and correct technique with low-dose ICS (with or without LABA).
High-dose ICS (in combination with LABA or separately) is needed by very few patients, and its long-term use is
associated with an increased risk of local and systemic side-effects, which must be balanced against the potential
benefits. For medications and doses of ICS-formoterol for GINA Track 1, see Box 3-15, p.80).

TE
Daily doses in this table are shown as metered doses. See product information for delivered doses.

U
IB
Adults and adolescents (12 years and older)

TR
Total daily ICS dose (mcg) – see notes above

IS
Inhaled corticosteroid (alone or in combination with LABA)
Low Medium High

D
R
Beclometasone dipropionate (pMDI, standard particle, HFA) 200–500 >500–1000 >1000

O
PY
Beclometasone dipropionate (DPI or pMDI, extrafine particle, HFA) O 100–200 >200–400 >400
Budesonide (DPI, or pMDI, standard particle, HFA) 200–400 >400–800 >800
C
T

Ciclesonide (pMDI, extrafine particle, HFA) 80–160 >160–320 >320

O
N

Fluticasone furoate (DPI) 100 200

O
-D

Fluticasone propionate (DPI) 100–250 >250–500 >500

L

Fluticasone propionate (pMDI, standard particle, HFA) 100–250 >250–500 >500

IA
ER

Mometasone furoate (DPI) Depends on DPI device – see product information

AT

Mometasone furoate (pMDI, standard particle, HFA) 200–400 >400

M
D

Children 6–11 years – see notes above (for children 5 years and younger, see Box 6-7, p.184)
TE

Beclometasone dipropionate (pMDI, standard particle, HFA) 100–200 >200–400 >400

H
IG

Beclometasone dipropionate (pMDI, extrafine particle, HFA) 50–100 >100–200 >200

R
PY

Budesonide (DPI, or pMDI, standard particle, HFA) 100–200 >200–400 >400

O
C

Budesonide (nebules) 250–500 >500–1000 >1000

Ciclesonide (pMDI, extrafine particle*, HFA) 80 >80–160 >160
Fluticasone furoate (DPI) 50 n.a.
Fluticasone propionate (DPI) 50–100 >100–200 >200
Fluticasone propionate (pMDI, standard particle, HFA) 50–100 >100–200 >200
Mometasone furoate (pMDI, standard particle, HFA) 100 200
See list of abbreviations (p.10). ICS by pMDI should preferably be used with a spacer.

For new preparations, including generic ICS, the manufacturer’s information should be reviewed carefully, as products
containing the same molecule may not be clinically equivalent. Combination inhalers that include a long-acting
muscarinic antagonist (LAMA) may have different ICS dosing – see product information.

3. Treating to control symptoms and minimize future risk 67

Choice of medication, device and dose
In clinical practice, the choice of medication, device and dose for maintenance and for reliever for each individual patient
should be based on assessment of symptom control, risk factors, which inhalers are available for the relevant
medication class, which of these the patient can use correctly after training, their cost, their environmental impact and
the patient’s likely adherence. For more detail about choice of inhaler, see Chapter 3.3 and Box 3-21 (p.99). It is
important to monitor the response to treatment and any side-effects, and to adjust the dose accordingly (Box 3-12, p.65).
Once good symptom control has been maintained for 2–3 months, the ICS dose should be carefully back-titrated to the
minimum dose that will maintain good symptom control and minimize exacerbation risk, while reducing the potential for
side-effects (Box 3-16, p.83). Patients who are being considered for a high daily dose of ICS (except for short periods)
should be referred for expert assessment and advice, where possible (Chapter 3.5, p.120). There is currently insufficient
good-quality evidence to support use of extrafine-particle ICS aerosols over others.206
GINA recommends that all adults and adolescents and all children 6–11 years should receive ICS-containing
medication, incorporated in their maintenance and/or anti-inflammatory reliever treatment as part of personalized

TE
asthma management. For adults and adolescents, treatment options are shown in Box 3-12; p.65; and, for children 6–11

U
IB
years, in Box 3-13; p.66. Clinicians should check local eligibility and payer criteria before prescribing.

TR
The evidence supporting treatment options at each step is summarized below.

IS
D
R
ASTHMA TREATMENT STEPS FOR ADULTS, ADOLESCENTS AND CHILDREN 6–11 YEARS

O
PY
The steps below refer to the recommended asthma treatment options shown in Box 3-12, p.65 for adults and
O
adolescents, and in Box 3-13, p.66 for children 6–11 years. Treatment recommendations for adults and adolescents are
C
shown in two treatment Tracks (description on p.58), for clarity. Suggested low, medium and high doses for a range of
T
O

ICS formulations are shown in Box 3-14 (p.67). Medication options and doses for GINA Track 1 are listed in Box 3-15
N

(p.80).
O
-D
L

STEP 1
IA
ER
AT

Preferred Step 1 treatment for adults and adolescents: low-dose combination ICS-formoterol taken as needed for
M

relief of symptoms, and if needed before exercise (Track 1)

D
TE

Population: GINA Step 1 recommendations are for:

H

• Initial asthma treatment in patients with symptoms less than twice a month and no exacerbation risk factors, a group
IG

that is rarely studied

R
PY

• Step-down treatment for patients whose asthma is well controlled on regular ICS or LTRA.
O
C

In Track 1, the preferred treatment (as-needed ICS-formoterol) is the same for Steps 1 and 2.
Evidence: Use of low-dose ICS-formoterol as needed for symptom relief (an anti-inflammatory reliever) in Step 1 for
adults and adolescents (Evidence B) is supported by indirect evidence for a reduction in risk of severe exacerbations
compared with as-needed SABA alone, from a large double-blind study202 and an open-label study171 in patients who
were eligible for Step 2 therapy (see below), and by direct evidence from two studies in patients previously taking Step 2
treatment (maintenance ICS or LTRA).207
Together, the four large studies showed a similar or greater reduction in severe exacerbations, compared with daily ICS,
with no clinically important difference in symptom control or lung function.171,172 For patients previously taking SABA
alone, the risk of severe exacerbations was 26% lower with as-needed low-dose ICS-formoterol compared with daily
ICS;207 it was also significantly lower than with daily ICS in an open-label study in patients previously taking SABA
alone.171

68 3. Treating to control symptoms and minimize future risk

 Among patients stepping down from regular ICS or LTRA, as-needed ICS-formoterol was associated with a similar207 or
greater172 reduction in severe exacerbations compared with taking daily ICS. Findings were similar in the adolescent
subgroup.208 No new safety signals were seen with as-needed budesonide-formoterol in mild asthma.171,172,202,203,210
Considerations: There were several important considerations for extending the Step 2 recommendation for as-needed-
only low-dose ICS-formoterol to Step 1 (i.e., eliminating SABA-only treatment):
• Patients with few interval asthma symptoms can still have severe or fatal exacerbations.164 GINA recommends
assessing and addressing risk factors for exacerbations as well as symptom control (Box 2-2).
• The historic distinction between so-called ‘intermittent’ and ‘mild persistent’ asthma is arbitrary, with no evidence
of difference in response to ICS.166 A large reduction in risk of severe exacerbations with as-needed ICS-
formoterol, compared with as-needed SABA, was seen even in patients with SABA use twice a week or less at
baseline.171
• A post hoc analysis of one study found that a single day with increased as-needed budesonide-formoterol
reduced the short-term (21-day) risk of severe exacerbations compared to as needed SABA alone, suggesting
that timing of use of ICS-formoterol is important.79

TE
• In patients with infrequent symptoms, adherence with prescribed daily ICS is very poor,211 exposing them to

U
IB
risks of SABA-only treatment if they are prescribed daily ICS plus as-needed SABA

TR
• There is a lack of evidence for the safety or efficacy of SABA-only treatment. Historic recommendations for

IS
SABA-only treatment were based on the assumption that patients with mild asthma would not benefit from ICS

D
R
• Taking SABA regularly for as little as one week significantly increases exercise-induced bronchoconstriction,

O
airway hyperresponsiveness and airway inflammation, and decreases bronchodilator response.212
PY
• Even modest over-use of SABA (indicated by dispensing of 3 or more 200-dose canisters a year) is associated
O
C
with increased risk of severe exacerbations74 and, in one study, asthma mortality.75
T

• GINA places a high priority on avoiding patients becoming reliant on SABA, and on avoiding conflicting
O
N

messages in asthma education. Previously, patients were initially provided only with SABA for symptom relief,
O

but later, despite this treatment being effective from the patient’s perspective, they were told that in order to
-D

reduce their SABA use, they needed to take a daily maintenance treatment, even when they had no symptoms.
L
IA

Recommending that all patients should be provided with ICS-containing treatment from the start of therapy
ER

(including, in mild asthma, the option of as-needed ICS-formoterol) allows consistent messaging about the need
AT

for both symptom relief and risk reduction, and may avoid establishing patient reliance on SABA as their main
M

asthma treatment.
D
TE

Practice points for as-needed-only ICS-formoterol in mild asthma

H
IG

The usual dose of as-needed budesonide-formoterol in mild asthma is a single inhalation of 200/6 mcg (delivered dose
R

160/4.5 mcg), taken whenever needed for symptom relief. The maximum recommended dose of as-needed
PY

budesonide-formoterol in a single day corresponds to a total of 72 mcg formoterol (54 mcg delivered dose). However, in
O
C

RCTs in mild asthma, such high usage was rarely seen, with average use around 3–4 doses per week.171,202,203 For
more details about medications and doses for as-needed-only ICS-formoterol, see Box 3-15 (p.80).
Rinsing the mouth is not generally needed after as-needed doses of low-dose ICS-formoterol, as this was not
required in any of the mild asthma studies (or in MART studies), and there was no increase in risk of oral thrush.210
ICS-formoterol formulations other than budesonide-formoterol have not been studied for as-needed-only use, but
beclometasone-formoterol may also be suitable. Both of these medications are well-established for as-needed use
within maintenance and reliever therapy in GINA Steps 3–5.213 Combination ICS with non-formoterol LABA cannot be
used as-needed for symptom relief.
For pre-exercise use in patients with mild asthma, one 6-week study showed that use of low-dose budesonide-
formoterol for symptom relief and before exercise reduced exercise-induced bronchoconstriction to a similar extent as
regular daily low-dose ICS with SABA for symptom relief and before exercise.214 More studies are needed, but this study
suggests that patients with mild asthma who are prescribed as-needed low-dose ICS-formoterol to prevent

3. Treating to control symptoms and minimize future risk 69

 exacerbations and control symptoms can use the same medication prior to exercise, if needed, and do not need to be
prescribed a SABA for pre-exercise use (Evidence B).
Alternative Step 1 treatment options for adults and adolescents (Track 2)
Low-dose ICS taken whenever SABA is taken (Evidence B): For patients with symptoms less than twice a month or
eligible to step-down from regular ICS treatment, there is very little evidence about the safety and efficacy of taking ICS
whenever SABA is taken (in separate or combination inhalers). However, it may be an option in countries where
ICS-formoterol is not available or affordable. In Step 1, the evidence for this strategy is indirect, from small studies with
separate or combination ICS and SABA inhalers in patients eligible for Step 2 treatment (see below).215-218 In making this
recommendation, the most important considerations were reducing the risk of severe exacerbations, and the difficulty of
achieving good adherence with regularly prescribed ICS in patients with infrequent symptoms. For definitions of low-
dose ICS see Box 3-14 (p.67).
Regular daily low-dose ICS has been suggested by GINA since 2014 for consideration as a Step 1 treatment for patients
with symptoms less than twice a month, to reduce the risk of exacerbations. This was based on indirect evidence from

TE
studies in patients eligible for Step 2 treatment166,209,219 (Evidence B). However, patients with symptoms less than twice a

U
IB
month are extremely unlikely to take ICS regularly even if prescribed, leaving them exposed to the risks of SABA-only

TR
treatment, so this regimen is no longer recommended for general use in such patients.

IS
Step 1 treatment options for children 6–11 years

D
R
O
For children 6–11 years with asthma symptoms less than twice a month, possible treatment options include taking ICS

PY
whenever SABA is taken, based on indirect evidence from Step 2 studies with separate inhalers in children and
O
adolescents. One of these studies showed substantially fewer exacerbations compared with SABA-only treatment,216
C

and another showed similar outcomes as with physician-adjusted treatment and with lower average ICS dose218
T
O

(Evidence B). Regular ICS plus as-needed SABA is also a possible option for this age-group (Evidence B), but the
N

likelihood of poor adherence in children with infrequent symptoms should be taken into account. See Box 3-14 (p.67) for
O
-D

ICS doses.
L
IA

There have been no studies of as needed-only ICS-formoterol in children aged 6–11 years. However, concerns around
ER

SABA-only treatment are also relevant to children and should be considered when initiating Step 1 treatment (see other
AT

controller options for children in Step 2, below).

M

Not recommended
D
TE

GINA no longer recommends SABA-only treatment of asthma in adults, adolescents or children 6–11 years.
H
IG

Although inhaled SABAs are highly effective for the quick relief of asthma symptoms,220 patients whose asthma is
R

treated with SABA alone (compared with ICS) are at increased risk of asthma-related death (Evidence A)75,221 and
PY

urgent asthma-related healthcare (Evidence A),222 even if they have good symptom control.223 The risk of severe
O
C

exacerbations requiring urgent health care is substantially reduced in adults and adolescents by either as-needed ICS-
formoterol,167 or by regular low-dose ICS with as-needed SABA.219 The risk of asthma exacerbations and mortality
increases incrementally with higher SABA use, including in patients treated with SABA alone.75 One long-term study of
regular SABA in patients with newly diagnosed asthma showed worse outcomes and lower lung function than in patients
who were treated with daily low-dose ICS from the start.224
In adults, inhaled short-acting anticholinergic agents like ipratropium are potential alternatives to SABA for routine relief
of asthma symptoms; however, these agents have a slower onset of action than inhaled SABA. Oral SABA and
theophylline have a higher risk of side-effects and are not recommended. For clinicians in regions without access to
inhaled therapies, advice on minimizing the frequency and dose of these oral medications has been provided
elsewhere.9 No long-term safety studies have been performed to assess the risk of severe exacerbations associated
with oral SABA or theophylline use in patients not also taking ICS. Use of long-acting muscarinic antagonists (LAMA) in
asthma without concomitant ICS is associated with an increased risk of severe exacerbations.225

70 3. Treating to control symptoms and minimize future risk

 The rapid-onset LABA, formoterol, is as effective as SABA as a reliever medication in adults and children,226 and
reduces the risk of severe exacerbations by 15–45%, compared with as-needed SABA,227-229 but use of regular or
frequent LABA without ICS is strongly discouraged because of the risk of exacerbations135,230 (Evidence A).

STEP 2

Preferred Step 2 treatment for adults and adolescents: low-dose ICS-formoterol, taken as-needed for relief of
symptoms and, if needed, before exercise (Track 1)
Population: patients enrolled in these studies were considered by their physicians to have mild asthma, with symptoms
or SABA use up to twice a day on SABA alone or regular ICS or LTRA plus as-needed SABA.
Evidence: The current evidence for this treatment in Step 2 is with low-dose budesonide-formoterol:
• A large double-blind study in mild asthma found a 64% reduction in severe exacerbations, compared with
SABA-only treatment,202 with a similar finding in an open-label study in patients with mild asthma previously

TE
taking SABA alone (Evidence A).171

U
• Two large double-blind studies in mild asthma showed as-needed budesonide-formoterol was non-inferior for

IB
TR
severe exacerbations, compared with regular ICS.202,203

IS
• In two open-label randomized controlled trials, representing the way that patients with mild asthma would use

D
as-needed ICS-formoterol in real life, as-needed budesonide-formoterol was superior to maintenance ICS in

R
O
reducing the risk of severe exacerbations (Evidence A).171,172

PY
• A Cochrane review provided moderate to high certainty evidence that as-needed ICS-formoterol was clinically
O
effective in adults and adolescents with mild asthma, significantly reducing important clinical outcomes including
C

need for oral corticosteroids, severe exacerbation rates, and emergency department visits or hospital
T
O

admissions compared with daily ICS plus as-needed SABA (Evidence A).167,210
N
O

• In all four studies, the as-needed low-dose ICS-formoterol strategy was associated with a substantially lower
-D

average ICS dose than with maintenance low-dose ICS.171,172,202,203

L

• Clinical outcomes with as-needed ICS-formoterol were similar in adolescents as in adults.208

IA
ER

• A post hoc analysis of one study202 found that a day with >2 doses of as-needed budesonide-formoterol reduced
AT

the short-term (21 day) risk of severe exacerbations compared to as needed terbutaline alone, suggesting that
M

timing of use of ICS-formoterol is important.79

D

• No new safety signals were seen with as-needed budesonide-formoterol in mild asthma.171,172,202,203,210
TE
H

Considerations: The most important considerations for GINA in recommending as-needed-only low-dose ICS-
IG

formoterol in Step 2 were:

R
PY

• The need to prevent severe exacerbations in patients with mild or infrequent symptoms; these can occur with
O

unpredictable triggers such as viral infection, allergen exposure, pollution or stress.

C

• The desire to avoid the need for daily ICS in patients with mild asthma, who in clinical practice are often poorly
adherent with prescribed ICS, leaving them exposed to the risks of SABA-only treatment.219
• The greater reduction in severe exacerbations with as-needed ICS-formoterol, compared with daily ICS, among
patients previously taking SABA alone, with no significant difference for patients with well-controlled asthma on
ICS or LTRA at baseline.171,207
• The very small differences in FEV1, (approximately 30–50 mL), symptom control (difference in ACQ-5 of
approximately 0.15 versus minimal clinically important difference 0.5), and symptom-free days (mean difference
10.6 days per year)202,203 compared with regular ICS were considered to be less important. These differences
did not increase over the 12-month studies. The primary outcome variable of one study202 was ‘well-controlled
asthma weeks’, but this outcome was not considered reliable because it was based on an earlier concept of
asthma control, and was systematically biased against the as-needed ICS-formoterol treatment group because
much less ICS was permitted in a week for patients on ICS-formoterol than those on maintenance ICS before
the week was classified as not well controlled.

3. Treating to control symptoms and minimize future risk 71

 • The similar reduction in FeNO with as-needed budesonide-formoterol as with maintenance ICS, and the lack of
significant difference in treatment effect with as-needed budesonide-formoterol by patients’ baseline eosinophils
or baseline FeNO.171,172
Anti-inflammatory reliever treatment with as-needed-only ICS-formoterol (‘AIR-only’) is the preferred treatment for Steps
1 and 2 in adults/adolescents, so these steps have been combined in the treatment figure (Track 1, Box 3-12, p.65) to
avoid confusion.
Practice points for as-needed ICS-formoterol in mild asthma
Patient preferences: from qualitative research, the majority of patients in a pragmatic open-label study preferred as-
needed ICS-formoterol for ongoing treatment rather than regular daily ICS with a SABA reliever. They reported that
shared decision-making would be important in choosing between these treatment options.231
The usual dose of as-needed budesonide-formoterol in mild asthma is a single inhalation of 200/6 mcg (delivered dose
160/4.5 mcg), taken whenever needed for symptom relief. Based on product information, the maximum recommended

TE
dose of budesonide-formoterol in a single day is a total of 72 mcg formoterol (54 mcg delivered dose). However, in the

U
randomized controlled trials in mild asthma, such high usage was rarely seen, and average use of as-needed

IB
ICS-formoterol was around 3–4 doses per week.171,172,202,203 For more details about medications and doses for

TR
as-needed-only ICS-formoterol, see Box 3-15 (p.80).

IS
D
Rinsing the mouth is not generally needed after as-needed use of low-dose ICS-formoterol, as this was not required

R
O
in any of the mild asthma studies (or MART studies), and there was no increase in risk of oral thrush.

PY
Other ICS-formoterol formulations have not been studied for as-needed-only use, but beclometasone-formoterol may
O
C
also be suitable. Both of these medications are well established for as-needed use within maintenance and reliever
T

therapy (MART) in GINA Steps 3–5.213 No new safety signals were seen in four studies with as-needed budesonide-
O
N

formoterol in mild asthma.171,172,202,203,210 ICS-LABA combinations with a non-formoterol LABA are not suitable for this
O

regimen.
-D
L

For pre-exercise use in patients with mild asthma, one study showed that budesonide-formoterol taken as-needed and
IA

before exercise had similar benefit in reducing exercise-induced bronchoconstriction as daily ICS with SABA as-needed
ER

and pre-exercise.214 More studies are needed, but this suggests that patients with mild asthma who are prescribed as-
AT

needed low-dose ICS-formoterol to prevent exacerbations and control symptoms can use the same medication prior to
M

exercise, if needed, and do not need to be prescribed a SABA for pre-exercise use (Evidence B).
D
TE
H

Alternative Step 2 treatment for adults and adolescents: daily low-dose ICS plus as-needed SABA (Track 2)
IG
R

Population: Most studies of daily low dose ICS have included patients with symptoms up to most or all days a week.
PY
O

Evidence: regular daily low-dose ICS plus as-needed SABA is a long-established treatment for mild asthma. There
C

is a large body of evidence from RCTs and observational studies showing that the risks of severe exacerbations,
hospitalizations and mortality are substantially reduced with regular low-dose ICS; symptoms and exercise-induced
bronchoconstriction are also reduced209,219,221,232,233 (Evidence A). Severe exacerbations are halved with low-dose ICS
even in patients with symptoms 0–1 days a week.166 In a meta-analysis of long-term longitudinal studies, regular ICS
was associated with a very small increase in pre- and post-bronchodilator FEV1 % predicted, in adults but not in
children, compared with SABA alone.234
Other considerations: Clinicians should be aware that adherence with maintenance ICS in the community is extremely
low. They should consider the likelihood that patients with infrequent symptoms who are prescribed daily ICS plus
as-needed SABA will be poorly adherent with the ICS, increasing their risk of severe exacerbations.
Over-use of SABA, indicated by dispensing of three or more 200-dose canisters of SABA in a year (i.e. average use
more than daily), is associated with an increased risk of severe exacerbations74,75 and, in one study, with increased
mortality,75 even in patients also taking ICS-containing treatment.

72 3. Treating to control symptoms and minimize future risk

Other Step 2 treatment options for adults and adolescents
Low-dose ICS taken whenever SABA is used (in combination or separate ICS and SABA inhalers) is another option if
as-needed ICS-formoterol is not available, and the patient is unlikely to take regular ICS. The evidence is from two small
studies in adults and two small studies in children and adolescents, with separate or combination ICS and SABA
inhalers,215-218 showing no difference in exacerbations compared with daily ICS. If combination ICS-SABA is not
available, the patient needs to carry both ICS and SABA inhalers with them for as-needed use. See Box 3-14 (p.67) for
ICS doses. There are no studies with daily maintenance ICS plus as-needed combination ICS-SABA.
Leukotriene receptor antagonists (LTRA) are less effective than ICS,235 particularly for exacerbations (Evidence A).
Before prescribing montelukast, health professionals should consider its benefits and risks, and patients should be
counselled about the risk of neuropsychiatric events. In 2020, the US Food and Drug Administration (FDA) required a
boxed warning to be added about the risk of serious mental health adverse effects with montelukast.236
Regular daily combination low-dose ICS-LABA as the initial maintenance controller treatment (i.e. in patients previously
treated with SABA alone) reduces symptoms and improves lung function, compared with low-dose ICS.237 However, it is

TE
more expensive and does not further reduce the risk of exacerbations compared with ICS alone237 (Evidence A).

U
IB
For patients with purely seasonal allergic asthma, e.g., with birch pollen, with no interval asthma symptoms, regular daily

TR
ICS or as-needed low-dose ICS-formoterol should be started immediately symptoms commence, and be continued for

IS
four weeks after the relevant pollen season ends (Evidence D).

D
R
O
Preferred Step 2 treatment for children 6–11 years

PY
The preferred controller option for children at Step 2 is regular low-dose ICS plus as-needed SABA (see Box 3-14, p.67
O
C
for ICS dose ranges in children). This reduces the risk of serious exacerbations compared with SABA-only treatment.219
T
O

Alternative Step 2 treatment for children 6–11 years

N
O

Another controller option for children is taking low-dose ICS whenever SABA is taken, based on the results of two small
-D

studies with separate ICS and SABA inhalers in patients aged between 5 years and 17 or 18 years.216,218 Exacerbations
L

and symptoms were similar with this regimen as with maintenance ICS plus as-needed SABA. Interviews with
IA
ER

parents/caregivers indicated that those whose children were randomized to as-needed ICS-SABA felt more in control of
AT

their child’s asthma than those whose children were randomized to physician-based adjustment.218
M

Another option is daily LTRA, which, overall, is less effective than ICS.235 The FDA warning about montelukast (above)
D
TE

also applies to its use in children.236

H
IG

Not recommended
R
PY

Sustained-release theophylline has only weak efficacy in asthma238-240 (Evidence B) and side-effects are common, and
O

may be life-threatening at higher doses.241 Use of long-acting muscarinic antagonists (LAMA) in asthma without
C

concomitant ICS is associated with an increased risk of severe exacerbations.225 Chromones (nedocromil sodium and
sodium cromoglycate) have been discontinued globally; these had a favorable safety profile but low efficacy242-244
(Evidence A), and their pMDI inhalers required burdensome daily washing to avoid blockage.

3. Treating to control symptoms and minimize future risk 73

 STEP 3

Before considering a step up, check for common problems such as incorrect inhaler technique, poor adherence, and
environmental exposures, and confirm that the symptoms are due to asthma (Box 2-4, p.45).
Preferred Step 3 treatment for adults and adolescents: low-dose ICS-formoterol maintenance and reliever therapy
(Track 1)
For adults and adolescents, the ‘preferred’ Step 3 option is low-dose ICS-formoterol as both maintenance and reliever
treatment (MART). In this regimen, low-dose ICS-formoterol, either budesonide-formoterol or beclometasone-formoterol,
is used as both the daily maintenance treatment and as an anti-inflammatory reliever for symptom relief.
Population: Double-blind studies included adult and adolescent patients with ≥1 exacerbation in the previous year
despite maintenance ICS or ICS-LABA treatment, usually with poor symptom control.
Evidence: Low-dose ICS-formoterol maintenance and reliever therapy reduced severe exacerbations and provided

TE
similar levels of asthma control at relatively low doses of ICS, compared with a fixed dose of ICS-LABA as maintenance

U
IB
treatment or a higher dose of ICS, both with as-needed SABA245-250 (Evidence A). In a meta-analysis, switching patients

TR
with uncontrolled asthma from Step 3 treatment to MART was associated with a 29% reduced risk of severe

IS
exacerbation compared with stepping up to Step 4 ICS-LABA maintenance plus SABA reliever, and a 30% reduced risk

D
compared with staying on the same treatment with SABA reliever.251 In open-label studies that did not require a history

R
O
of severe exacerbations, maintenance and reliever therapy with ICS-formoterol also significantly reduced severe
exacerbations, with a lower average dose of ICS.245,252
PY
O
C
Other considerations: Use of ICS-formoterol as an anti-inflammatory reliever across treatment steps provides a simple
T
O

regimen with easy transition if treatment needs to be stepped up (e.g. from Step 2 to Step 3, or Step 3 to Step 4),
N

without the need for an additional medication or different prescription, or a different inhaler type (see Box 3-15, p.80).
O
-D

Practice points for maintenance and reliever therapy (MART) with low-dose ICS-formoterol
L
IA

Medications: ICS-formoterol maintenance and reliever therapy for Step 3 treatment can be prescribed with low-dose
ER

budesonide-formoterol (≥12 years) or low-dose beclometasone-formoterol (≥18 years). The usual dose of budesonide-
AT

formoterol for MART is 200/6 mcg metered dose (160/4.5 mcg delivered dose) and the usual dose of beclometasone-
M

formoterol is 100/6 metered dose (87.5/5 mcg), with each of these combinations prescribed as one inhalation twice-daily
D
TE

and one inhalation whenever needed for symptom relief.

H

Doses: The maximum recommended total dose of formoterol in a single day (total of maintenance and reliever doses,
IG
R

based on product information, is 72 mcg metered dose (54 mcg delivered dose) for budesonide-formoterol and 48 mcg
PY

metered dose (36 mcg delivered dose) for beclometasone-formoterol. For a summary of medications and doses, see
O

Box 3-15 (p.80).

C

ICS-formoterol should not be used as the reliever for patients taking a different ICS-LABA maintenance treatment, since
clinical evidence for safety and efficacy is lacking.
Rinsing the mouth is not generally needed after as-needed doses of ICS-formoterol, as this was not required in any
of the MART studies, and there was no increase in risk of oral thrush.
Additional practice points can be found in an article describing how to use MART, including a customizable written
asthma action plan for use with this regimen.8
Alternative Step 3 treatment for adults and adolescents: maintenance low-dose ICS-LABA plus as-needed SABA
or plus as-needed combination ICS-SABA (Track 2)
Currently approved combination ICS-LABA inhalers for Step 3 maintenance treatment of asthma include low doses of
fluticasone propionate-formoterol, fluticasone furoate-vilanterol, fluticasone propionate-salmeterol, beclometasone-
formoterol, budesonide-formoterol, mometasone-formoterol, and mometasone-indacaterol (see Box 3-14, p.67).

74 3. Treating to control symptoms and minimize future risk

 Effectiveness of fluticasone furoate-vilanterol over usual care was demonstrated for asthma symptom control in a large
real-world study, but there was no significant difference in risk of exacerbations.253,254
Maintenance ICS-LABA plus as-needed SABA: This is an alternative approach if MART is not possible, or if a patient’s
asthma is stable with good adherence and no exacerbations on their current therapy. For patients taking maintenance
ICS, changing to maintenance combination ICS-LABA provides additional improvements in symptoms and lung function
with a reduced risk of exacerbations compared with the same dose of ICS (Evidence A),255,256 but there is only a small
reduction in reliever use.257,258 In these studies, the reliever was as-needed SABA. However, before prescribing a
regimen with SABA reliever, consider whether the patient is likely to be adherent with their ICS-containing treatment, as
otherwise they will be at higher risk of exacerbations.
Maintenance ICS-LABA plus as-needed combination ICS-SABA (≥18 years):
Population: In the double-blind MANDALA study,259 the population relevant to Step 3 recommendations comprised
patients with poor asthma control and a history of severe exacerbations who were taking maintenance low-dose ICS-
LABA or medium-dose ICS. In this study, patients were randomized to as-needed ICS-SABA or as-needed SABA, and

TE
continued to take their usual maintenance treatment.

U
Evidence: In the sub-population taking Step 3 maintenance treatment, as-needed use of 2 inhalations of budesonide-

IB
TR
salbutamol (albuterol) 100/100 mcg metered dose (80/90 mcg delivered dose), taken for symptom relief, increased the

IS
time to first severe exacerbation by 41% compared with as-needed salbutamol (hazard ratio 0.59; CI 0.42–0.85). The

D
proportion of patients with a clinically important difference in ACQ-5 was slightly higher with the budesonide-salbutamol

R
O
reliever. A formulation with a lower ICS dose did not significantly reduce severe exacerbations.259

PY
Other considerations: There are no head-to-head comparisons between this regimen and ICS-formoterol
O
maintenance-and-reliever therapy (MART), both of which include an anti-inflammatory reliever (AIR). However, as ICS-
C
T

SABA is not recommended for regular use, and its use as the reliever in Steps 3–5 requires the patient to have different
O
N

maintenance and reliever inhalers, this regimen is more complex for patients than GINA Track 1 with ICS-formoterol, in
O

which the same medication is used for both maintenance and reliever doses. Transition between treatment steps with
-D

as-needed ICS-SABA may also be more complex than in GINA Track 1 as there is only one small study of as-needed-
L

only ICS-SABA (beclometasone-salbutamol) as a Step 2 treatment.215

IA
ER

Practice points: A maximum number of 6 as-needed doses (each 2 puffs of 100/100 mcg budesonide-salbutamol
AT

[80/90 mcg delivered dose]) can be taken in a day. It is essential to educate patients about the different purpose of their
M

maintenance and reliever inhalers, and to train them in correct inhaler technique with both devices if they are different;
D

this also applies to SABA relievers.

TE
H

Other Step 3 controller options for adults and adolescents

IG
R

For adult patients with allergic rhinitis and sensitized to house dust mite, with suboptimally controlled asthma despite low
PY

to high-dose ICS, consider adding sublingual allergen immunotherapy (SLIT), provided FEV1 is >70% predicted.260,261
O
C

(see p.86).
Another option for adults and adolescents is to increase ICS to medium dose150 (see Box 3-14, p.67) but, at population
level, this is less effective than adding a LABA262,263 (Evidence A). Other less efficacious options are low-dose ICS-
containing therapy plus either LTRA264 (Evidence A) or low-dose, sustained-release theophylline265 (Evidence B). Note
the FDA warning for montelukast.236
Preferred Step 3 treatment for children 6–11 years
In children, after checking inhaler technique and adherence, and treating modifiable risk factors, there are three
preferred options at a population level:
• Increase ICS to medium dose (see Box 3-14, p.67),266 plus as-needed SABA reliever (Evidence A), or
• Change to combination low-dose ICS-LABA plus as-needed SABA reliever (Evidence A),267 or
• Switch to maintenance-and-reliever therapy (MART) with a very low dose of ICS-formoterol (Evidence B).268 For a
summary of medications and doses, see Box 3-15 (p.80).

3. Treating to control symptoms and minimize future risk 75

 Evidence: In a large study of children aged 4–11 years with a history of an exacerbation in the previous year,
combination ICS-LABA was non-inferior to the same dose of ICS alone for severe exacerbations, with no difference in
symptom control or reliever use.269 In children, a single study of maintenance and reliever therapy with very low-dose
budesonide-formoterol (100/6 metered dose, 80/4.5 mcg delivered dose for both maintenance and reliever) showed a
large reduction in exacerbations, compared with the same dose of budesonide-formoterol plus SABA reliever, or
compared with higher-dose ICS.268
Individual children’s responses vary, so try the other controller options above before considering Step 4 treatment.270
Other Step 3 treatment options for children 6–11 years
In children, a 2014 systematic review and meta-analysis did not support the addition of LTRA to low-dose ICS.264 The
FDA warning about montelukast (above) also applies to its use in children.236

STEP 4

TE
U
Although at a population level most benefit from ICS is obtained at low dose, individual ICS responsiveness varies, and

IB
TR
some patients whose asthma is uncontrolled on low-dose ICS-LABA despite good adherence and correct inhaler
technique may benefit from increasing the maintenance dose to medium. High-dose ICS is no longer recommended at

IS
D
Step 4.

R
O
Before stepping up, check for common problems such as incorrect inhaler technique, poor adherence, and

PY
environmental exposures, and confirm that the symptoms are due to asthma (Box 2-4, p.45).
O
C
Preferred Step 4 treatment for adults and adolescents: medium-dose ICS-formoterol maintenance and reliever
T
O

therapy (Track 1)
N
O

For adult and adolescent patients, combination ICS-formoterol as both maintenance and reliever treatment (MART) is
-D

more effective in reducing exacerbations than the same dose of maintenance ICS-LABA or higher doses of ICS249
L

(Evidence A). The greatest reduction in risk was seen in patients with a history of severe exacerbations,213 but MART
IA
ER

was also significantly more effective than conventional best practice with as-needed SABA in open-label studies in
which patients were not selected for greater exacerbation risk.223
AT
M

In Step 4, the MART regimen can be prescribed with medium-dose maintenance budesonide-formoterol or
D
TE

beclometasone-formoterol treatment, by increasing the twice-daily maintenance dose to 2 inhalations, but the reliever
H

remains 1 inhalation of low-dose ICS-formoterol as needed. The usual dose of budesonide-formoterol for Step 4 MART
IG

is 200/6 mcg metered dose (160/4.5 mcg delivered dose) and the usual dose of beclometasone-formoterol is 100/6
R
PY

metered dose (87.5/5 mcg), with each of these combinations prescribed as two inhalations twice-daily and one
O

inhalation whenever needed for symptom relief. Based on product information, the maximum recommended total dose
C

of formoterol in a single day is 72 mcg metered dose (54 mcg delivered dose) for budesonide-formoterol and 48 mcg
metered dose (36 mcg delivered dose) for beclometasone-formoterol). For practice points, see information for GINA
Step 3 and an article for clinicians.8 For a summary of medications and doses, see Box 3-15 (p.80).
Alternative Step 4 treatment for adults and adolescents: medium or high-dose ICS-LABA plus as-needed SABA or
as-needed ICS-SABA (Track 2)
Maintenance medium- or high-dose ICS-LABA plus as-needed SABA: This is an alternative approach if MART is not
possible, or if a patient’s asthma is stable with good adherence and no exacerbations on their current therapy. As above,
individual ICS responsiveness varies, and some patients whose asthma is uncontrolled or who have frequent
exacerbations on low-dose ICS-LABA despite good adherence and correct inhaler technique may benefit from
maintenance medium-dose ICS-LABA271 (Evidence B) plus as-needed SABA, if MART is not available. However, before
prescribing a regimen with SABA reliever, consider whether the patient is likely to be adherent with their ICS-containing
treatment, as otherwise they will be at higher risk of exacerbations. Occasionally, high-dose ICS-LABA may be needed.

76 3. Treating to control symptoms and minimize future risk

 Maintenance ICS-LABA plus as-needed combination ICS-SABA (≥18 years):
Population: In the double-blind MANDALA study,259 the population relevant to Step 4 recommendations comprised
patients with poor asthma control and a history of severe exacerbations who were taking maintenance medium-dose
ICS-LABA or high-dose ICS.
Evidence: In the sub-population of patients who were taking maintenance medium-dose ICS-LABA or high-dose ICS
(Step 4 treatment), there was no significant increase in time to first severe exacerbation with as-needed budesonide-
salbutamol (albuterol) 2 inhalations of 100/200 mcg metered dose (80/90 mcg delivered dose), compared with as-
needed salbutamol (hazard ratio 0.81; CI 0.61–1.07). More studies in this population are needed.
Other considerations: There are no head-to-head comparisons between this regimen and ICS-formoterol MART, both
of which include an anti-inflammatory reliever. However, as ICS-SABA is not recommended for regular use, and its use
as the reliever in Steps 3–5 requires the patient to have different maintenance and reliever inhalers, this regimen is more
complex for patients than GINA Track 1 with ICS-formoterol in which the same medication is used for both maintenance
and reliever doses.

TE
Practice points: A maximum number of 6 as-needed doses (each 2 puffs of 100/100 mcg budesonide-salbutamol

U
[80/90 mcg delivered dose]) can be taken in a day. It is essential to educate patients about the different purpose of their

IB
maintenance and reliever inhalers, and to train them in correct inhaler technique with both devices if they are different;

TR
this also applies to SABA relievers.

IS
D
Other Step 4 controller options for adults and adolescents

R
O
Long-acting muscarinic antagonists: LAMAs may be considered as add-on therapy in a separate inhaler for patients
PY
aged ≥6 years (tiotropium), or in a combination (‘triple’) inhaler for patients aged ≥18 years (beclometasone-formoterol-
O
C
glycopyrronium; fluticasone furoate-vilanterol-umeclidinium; mometasone-indacaterol-glycopyrronium) if asthma is
T

persistently uncontrolled despite medium or high-dose ICS-LABA. Adding a LAMA to medium or high-dose ICS-LABA
O
N

modestly improved lung function205,272-275,252 (Evidence A) but with no difference in symptoms. In some studies, adding
O

LAMA to ICS-LABA modestly reduced exacerbations, compared with some medium- or high-dose ICS-LABA
-D

comparators.205,272,273,276 In a meta-analysis, there was a 17% reduction in risk of severe exacerbations with addition of
L
IA

LAMA to medium- or high-dose ICS-LABA.290

ER

However, for patients experiencing exacerbations despite low-dose ICS-LABA, the ICS dose should be increased to at
AT

least medium, or treatment switched to maintenance and reliever therapy with ICS-formoterol, before considering adding
M

a LAMA. In one study, the severe exacerbation rate was lower in patients receiving high-dose fluticasone furoate-
D
TE

vilanterol (ICS-LABA) than with low- to medium-dose fluticasone furoate-vilanterol-umeclidinium (ICS-LABA-LAMA).274

H

For patients prescribed an ICS-LABA-LAMA with a non-formoterol LABA, the appropriate reliever is SABA.
IG
R

In Step 4, there is insufficient evidence to support ICS-LAMA over low- or medium-dose ICS-LABA combination; all
PY

studies were with ICS and tiotropium in separate inhalers.272 In one analysis, response to adding LAMA to medium-dose
O
C

ICS, as assessed by FEV1, ACQ, and exacerbations, was not modified by baseline demographics, body-mass index,
FEV1, FEV1 reversibility, or smoking status (past smoking versus never).277
Allergen immunotherapy: Consider adding sublingual allergen immunotherapy (SLIT) for adult patients with allergic
rhinitis and sensitization to house dust mite, with suboptimally controlled asthma despite low- to high-dose ICS, but only
if FEV1 is >70% predicted.260,261 (see p.86).
Other options: For medium- or high-dose budesonide, efficacy may be improved with dosing four times daily278,279
(Evidence B), but adherence may be an issue. For other ICS, twice-daily dosing is appropriate (Evidence D). Other
options for adults or adolescents that can be added to a medium or high-dose ICS, but that are less efficacious than
adding LABA, include LTRA280-284 (Evidence A), or low-dose sustained-release theophylline239 (Evidence B), but neither
of these has been compared with maintenance and reliever therapy with ICS-formoterol. Note the FDA warning for
montelukast.236

3. Treating to control symptoms and minimize future risk 77

Preferred Step 4 treatment for children 6–11 years
For children whose asthma is not adequately controlled by low-dose maintenance ICS-LABA with as-needed SABA,
treatment may be increased to medium-dose ICS-LABA269 (Evidence B). For maintenance-and-reliever therapy (MART)
with budesonide-formoterol, the maintenance dose may be increased to 100/6 mcg twice daily (metered dose;
80/4.5 mcg delivered dose) (Evidence D); this is still a low-dose regimen. For a summary of medications and doses, see
Box 3-15 (p.80).
If asthma is not well controlled on medium-dose ICS (Box 3-14B, p.67), refer the child for expert assessment and
advice.
Other Step 4 options for children 6–11 years
Other controller options include increasing to high pediatric dose ICS-LABA (Box 3-14B, p.67), but adverse effects must
be considered. Tiotropium (a long-acting muscarinic antagonist) by mist inhaler may be used as add-on therapy in
children aged 6 years and older; it modestly improves lung function and reduces exacerbations (Evidence A),285 largely

TE
independent of baseline IgE or blood eosinophils.286 If not trialed before, LTRA could be added (but note the FDA

U
warning about montelukast).236 Add-on theophylline is not recommended for use in children due to lack of efficacy and

IB
safety data.

TR
IS
D
STEP 5

R
O
PY
Preferred treatment at Step 5 in adults, adolescents and children (Track 1 and Track 2): refer for expert
O
assessment, phenotyping, and add-on therapy
C
T

Patients of any age with persistent symptoms or exacerbations despite correct inhaler technique and good adherence
O
N

with Step 4 treatment and in whom other controller options have been considered, should be referred to a specialist with
O

expertise in investigation and management of severe asthma, if available159 (Evidence D).

-D
L

In severe asthma, as in mild–moderate asthma,287 participants in randomized controlled trials may not be representative
IA

of patients seen in clinical practice. For example, a registry study found that over 80% of patients with severe asthma
ER

would have been excluded from major regulatory studies evaluating biologic therapy.288
AT
M

Recommendations from the GINA Guide and decision tree on Diagnosis and Management of difficult-to-treat and
D

severe asthma in adolescent and adult patients are included in Chapter 3.5 (p.120). These recommendations
TE

emphasize the importance of first optimizing existing therapy and treating modifiable risk factors and comorbidities (see
H
IG

Box 3-26, p.123). If the patient still has uncontrolled symptoms and/or exacerbations, additional treatment options that
R

may be considered may include the following (always check local eligibility and payer criteria):
PY
O

• Combination high-dose ICS-LABA may be considered in adults and adolescents, but for most patients, the
C

increase in ICS dose generally provides little additional benefit144,150,263 (Evidence A), and there is an increased
risk of side-effects, including adrenal suppression.289 A high dose is recommended only on a trial basis for 3–6
months when good asthma control cannot be achieved with medium-dose ICS plus LABA and/or a third controller
(e.g. LTRA or sustained-release theophylline239,283 Evidence B).

• Add-on long-acting muscarinic antagonists (LAMA) can be prescribed in a separate inhaler for patients aged
≥6 years (tiotropium), or in a combination (‘triple’) inhaler for patients aged ≥18 years (beclometasone-formoterol-
glycopyrronium; fluticasone furoate-vilanterol-umeclidinium; mometasone-indacaterol-glycopyrronium) if asthma is
not well controlled with medium or high-dose ICS-LABA. Adding LAMA to ICS-LABA modestly improves lung
function (Evidence A),205,272-275,277,285,290 but not quality of life, with no clinically important change in symptoms.290
Some studies showed a reduction in exacerbation risk; in meta-analysis, overall, there was a 17% reduction in risk
of severe exacerbations requiring oral corticosteroids (Evidence A).205,272,273,276,285,290 For patients with
exacerbations despite ICS-LABA, it is essential that sufficient ICS is given, i.e., at least medium-dose ICS-LABA,

78 3. Treating to control symptoms and minimize future risk

 before considering adding a LAMA. For patients prescribed an ICS-LABA-LAMA with a non-formoterol LABA, the
appropriate reliever is SABA; patients prescribed ICS-formoterol-LAMA can continue ICS-formoterol reliever.
• Add-on azithromycin (three times a week) can be considered after specialist referral for adult patients with
persistent symptomatic asthma despite high-dose ICS-LABA. Before considering add-on azithromycin, sputum
should be checked for atypical mycobacteria, ECG should be checked for long QTc (and re-checked after a month
on treatment), and the risk of increasing antimicrobial resistance should be considered.291 Diarrhea is more
common with azithromycin 500 mg 3 times a week.292 Treatment for at least 6 months is suggested, as a clear
benefit was not seen by 3 months in the clinical trials.292,505 The evidence for this recommendation includes a
meta-analysis of two clinical trials292,505 in adults with persistent asthma symptoms that found reduced asthma
exacerbations among those taking medium or high-dose ICS-LABA who had either an eosinophilic or non-
eosinophilic profile and in those taking high-dose ICS-LABA (Evidence B).293 The option of add-on azithromycin
for adults is recommended only after specialist consultation because of the potential for development of antibiotic
resistance at the patient or population level.292

TE
• Add-on biologic therapy: options recommended by GINA for patients with uncontrolled severe asthma despite

U
optimized maximal therapy (see chapter 3.5 for more details) include:

IB
o Add-on anti-immunoglobulin E (anti-IgE) treatment (omalizumab) for patients aged ≥6 years with severe

TR
allergic asthma (Evidence A)294

IS
D
o Add-on anti-interleukin-5/5R treatment (subcutaneous mepolizumab for patients aged ≥6 years;

R
intravenous reslizumab for ages ≥18 years or subcutaneous benralizumab for ages ≥12 years), with severe

O
eosinophilic asthma (Evidence A).294-299
PY
o Add-on anti-interleukin-4Rα treatment (subcutaneous dupilumab) for patients aged ≥6 years with severe
O
C
eosinophilic/Type 2 asthma,300 or for adults or adolescents requiring treatment with maintenance OCS
T
O

(Evidence A)301-303
N

o Add-on anti-thymic stromal lymphopoietin (anti-TSLP) treatment (subcutaneous tezepelumab) for patients
O
-D

aged ≥12 years with severe asthma (Evidence A).304

L

• Sputum-guided treatment: for adults with persisting symptoms and/or exacerbations despite high-dose ICS or
IA
ER

ICS-LABA, treatment may be adjusted based on eosinophilia (>3%) in induced sputum. In severe asthma, this
AT

strategy leads to reduced exacerbations and/or lower doses of ICS (Evidence A),305 but few clinicians currently
M

have access to routine sputum testing.

D
TE

• Add-on treatment with bronchial thermoplasty may be considered for some adult patients with severe
H

asthma159,306 (Evidence B). Evidence is limited and in selected patients (see p.87). The long-term effects
IG

compared with control patients, including for lung function, are not known.
R
PY

• As a last resort, add-on low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) may be
O
C

considered for some adults with severe asthma (Evidence D),159 but they are often associated with substantial
side effects (Evidence A).307-310 They should only be considered for adults with poor symptom control and/or
frequent exacerbations despite good inhaler technique and adherence with Step 5 treatment, and after exclusion
of other contributory factors and other add-on treatments including biologics where available and affordable.
Patients should be counseled about potential side-effects.308,310 They should be assessed and monitored for risk
of adrenal suppression and corticosteroid-induced osteoporosis, and those expected to be treated for ≥3 months
should be provided with relevant lifestyle counseling and prescription of therapy for prevention of osteoporosis and
fragility fractures (where appropriate).311

• Maintenance and reliever therapy (MART) with ICS-formoterol: there is no evidence about initiating MART in
patients receiving add-on biologic therapy, but for a patient already taking MART, there is no reason to
discontinue this if biologic therapy is added. Studies are needed. For patients receiving triple therapy (ICS-LABA-
LAMA) with a non-formoterol LABA, the appropriate reliever is SABA or ICS-SABA.

3. Treating to control symptoms and minimize future risk 79

 Box 3-15. Medications and doses for GINA Track 1: anti-inflammatory reliever (AIR)-based therapy

• In GINA Track 1, the reliever is low dose ICS-formoterol, with or without maintenance ICS-formoterol. This is the
preferred treatment approach for adults and adolescents with asthma, because it reduces severe exacerbations
across treatment steps compared with using a SABA reliever; it uses a single medication for both reliever and
maintenance treatment (less confusing for patients); and a patient’s treatment can be stepped up and down if
needed without changing the medication or inhaler device. This cannot be done with any other ICS-LABA.
• Low dose ICS-formoterol is called an anti-inflammatory reliever (AIR) because it relieves symptoms and reduces
inflammation. AIR with ICS-formoterol significantly reduces the risk of severe exacerbations across treatment steps
compared with using a SABA reliever, with similar symptom control, lung function and adverse effects
• Steps 1–2 (AIR-only): low dose ICS-formoterol is used as needed for symptom relief without any maintenance
treatment. It reduces the risk of severe exacerbations and ED visits/hospitalizations by 65% compared with SABA
alone, and reduces ED visits/hospitalizations by 37% compared with daily ICS plus as-needed SABA.167 Starting
treatment with as-needed ICS-formoterol avoids training patients to regard SABA as their main asthma treatment.

TE
• Steps 3–5 (MART): maintenance-and-reliever therapy with ICS-formoterol reduces the risk of severe exacerbations

U
IB
by 32% compared with the same dose of ICS-LABA,213 by 23% compared with a higher dose of ICS-LABA,213 and by

TR
17% compared with usual care.245 MART is also an option for children 6–11 years in Steps 3–4.

IS
• Asthma action plan: Simple action plans for AIR-only and MART are available online.8,312

D
R
Which medications can be used in GINA Track 1, and how often?

O
PY
• Most evidence for MART, and all evidence for AIR-only, is with budesonide (BUD)-formoterol DPI, usually 200/6 mcg
O
metered dose (160/4.5 mcg delivered dose) for adults/adolescents, and 100/6 mcg (80/4.5) for MART in children 6–
C

11 years. Beclometasone (BDP)-formoterol 100/6 mcg (84.6/5.0) is approved for MART in adults. Other low-dose
T
O

combination ICS-formoterol products may be suitable but have not been studied.
N
O

• For as-needed use, patients should take 1 inhalation of ICS-formoterol whenever needed for symptom relief, or
-D

before exercise or allergen exposure, instead of a SABA reliever. See doses below.
L

• Advise patients to take extra inhalations when symptoms persist or recur, but to seek medical care if they need more
IA
ER

than the following total inhalations in a single day (as-needed + maintenance): BUD-formoterol adolescents and
adults 12* inhalations, children 8* inhalations; BDP-formoterol 8 inhalations. Most patients need far less than this.
AT
M

Step Age Medication and device Metered Delivered

Dosage
D

(years) (check patient can use inhaler) dose (mcg) dose (mcg)
TE

6–11 (No evidence) - - -

H

Steps 1–2
IG

12–17
(AIR-only)
R

Budesonide-formoterol DPI 200/6 160/4.5 1 inhalation whenever needed

≥18
PY

1 inhalation once daily,

O

6–11 Budesonide-formoterol DPI 100/6 80/4.5

C

PLUS 1 inhalation whenever needed

Step 3
12–17
MART Budesonide-formoterol DPI 200/6 160/4.5 1 inhalation once or twice daily,
≥18
PLUS 1 inhalation whenever needed
≥18 Beclometasone-formoterol pMDI 100/6 84.5/5.0
1 inhalation twice daily,
6–11 Budesonide-formoterol DPI 100/6 80/4.5
PLUS 1 inhalation whenever needed
Step 4
12–17
MART Budesonide-formoterol DPI 200/6 160/4.5 2 inhalations twice daily,
≥18
PLUS 1 inhalation whenever needed
≥18 Beclometasone-formoterol pMDI 100/6 84.5/5.0
6–11 (No evidence) - - -
Step 5 12–17;
Budesonide-formoterol DPI 200/6 160/4.5 2 inhalations twice daily,
MART ≥18
PLUS 1 inhalation whenever needed
≥18 Beclometasone-formoterol pMDI 100/6 84.5/5.0
*For budesonide-formoterol pMDIs with 3 mcg (2.25 mcg) formoterol, use double the number of inhalations. For abbreviations, see p.10

80 3. Treating to control symptoms and minimize future risk

REVIEWING RESPONSE AND ADJUSTING TREATMENT

How often should asthma be reviewed?

Patients with asthma should be reviewed regularly to monitor their symptom control, risk factors and occurrence of
exacerbations, as well as to document the response to any treatment changes. For most controller medications,
improvement in symptoms and lung function begins within days of initiating treatment, but the full benefit may only be
reached after 3–4 months.313 In severe and chronically under-treated disease, it may take longer.314
All health care providers should be encouraged to assess asthma control, adherence and inhaler technique at every
visit, not just when the patient presents because of their asthma.315 The frequency of visits depends upon the patient’s
initial level of control, their response to treatment, and their level of engagement in self-management.
Ideally, patients should be seen 1–3 months after starting treatment and every 3–12 months thereafter. After an
exacerbation, a review visit within 1 week should be scheduled (Evidence D).316

TE
Stepping up asthma treatment

U
IB
Asthma is a variable condition, and adjustments of controller treatment by the clinician and/or the patient may be

TR
needed.317

IS
• Day-to-day adjustment using an anti-inflammatory reliever (AIR): For patients whose reliever inhaler is

D
R
combination budesonide-formoterol or beclometasone-formoterol (with or without maintenance ICS-formoterol),

O
the patient adjusts the number of as-needed doses of ICS-formoterol from day to day according to their
PY
symptoms. This strategy reduces the risk of developing a severe exacerbation requiring oral corticosteroids within
O
the next 3–4 weeks.77-79 As-needed combination budesonide-salbutamol is an anti-inflammatory reliever option
C
T

that has been studied in Steps 3–5.259

O
N

• Short-term step up (for 1–2 weeks): A short-term increase in maintenance ICS dose for 1–2 weeks may be
O

necessary; for example, during viral infections or seasonal allergen exposure. This may be initiated by the patient
-D

according to their written asthma action plan (Box 4-2, p.61), or by the health care provider.
L
IA

• Sustained step up (for at least 2–3 months): Although at a group level most benefit from ICS is obtained at low
ER

dose, individual ICS responsiveness varies, and some patients whose asthma is uncontrolled on low-dose ICS-
AT

LABA despite good adherence and correct technique may benefit from increasing the maintenance dose to
M

medium. A step up in treatment may be recommended (Box 3-12, p.65) if it has been confirmed that the
D

symptoms are due to asthma, inhaler technique and adherence are satisfactory, and modifiable risk factors such
TE

as smoking have been addressed (Box 3-17, p.38). Any step-up should be regarded as a therapeutic trial. If there
H
IG

is no response after 2–3 months, treatment should be reduced to the previous level, and alternative treatments or
R

referral considered.
PY
O
C

Stepping down treatment when asthma is well controlled

Once good asthma control has been achieved and maintained for 2–3 months and lung function has reached a plateau,
treatment can often be successfully reduced, without loss of asthma control. The aims of stepping down are:
• To find the patient’s minimum effective treatment, i.e., to maintain good control of symptoms and exacerbations,
and to minimize the costs of treatment and potential for side-effects
• To encourage the patient to continue maintenance treatment. Patients often experiment with intermittent
treatment through concern about the risks or costs of daily treatment,318 but this leaves them exposed to the
risks of SABA-only treatment. For patients whose asthma is well controlled on maintenance low-dose ICS with
as-needed SABA, an alternative is to cease maintenance ICS and switch to as-needed low-dose
ICS-formoterol.202,203

3. Treating to control symptoms and minimize future risk 81

Before stepping down
The approach to stepping down will differ from patient to patient depending on their current treatment, risk factors and
preferences. There are few data on the optimal timing, sequence and magnitude of treatment reductions in asthma.
Factors associated with a greater risk of exacerbation after step-down include a history of exacerbations and/or
emergency department visit for asthma in the previous 12 months,319,320 and a low baseline FEV1.320 Other predictors of
loss of control during dose reduction include airway hyperresponsiveness and sputum eosinophilia,321 but these tests
are not readily available in primary care.
Any treatment step-down should be considered as a therapeutic trial, with the response evaluated in terms of both
symptom control and exacerbation frequency. Prior to stepping down, the patient should be provided with a written
asthma action plan and instructions for how and when to resume their previous treatment if their symptoms worsen.
How to step asthma treatment down
Decisions about treatment step-down should be made on an individual patient level. In one study of patients with well-

TE
controlled asthma on medium-dose ICS-LABA, reducing the ICS dose and removing the LABA had similar effects on a

U
composite treatment failure outcome. However, stopping LABA was associated with lower lung function and more

IB
hospitalizations; and decreasing the ICS dose was inferior to maintaining a stable dose of ICS-LABA.322

TR
IS
If treatment is stepped down too far or too quickly, exacerbation risk may increase even if symptoms remain reasonably

D
controlled323 (Evidence B). To date, higher baseline FeNO has not been found to be predictive of exacerbation following

R
O
step-down of ICS dose.324, 325 A meta-analysis suggested that greater reduction in ICS dose may be able to be achieved

PY
in patients with baseline FeNO <50 ppb, but the findings point to the need for further research.325 Complete cessation of
O
ICS is associated with a significantly increased risk of exacerbations326 (Evidence A).
C
T

Stepping down from daily low-dose ICS plus as-needed SABA to as-needed-only ICS-formoterol provides similar or
O
N

greater protection from severe exacerbations and need for urgent health care, with similar symptom control and lung
O

function and a much lower average daily ICS dose, compared with treatment with daily low-dose ICS plus as-needed
-D

SABA.167 Step-down strategies for different controller treatments are summarized in Box 3-16, p.83; these are based on
L
IA

current evidence, but more research is needed. Few step-down studies have been performed in children.
ER
AT
M
D
TE
H
IG
R
PY
O
C

82 3. Treating to control symptoms and minimize future risk

 Box 3-16. Options for stepping down treatment in adults and adolescents once asthma is well controlled

General principles of stepping down asthma treatment

• Consider stepping down when asthma symptoms have been well controlled and lung function has been stable
for 3 or more months (Evidence D). If the patient has risk factors for exacerbations (Box 2-2, p.38), for example a
history of exacerbations in the past year,319 or persistent airflow limitation, step down only with close supervision.
• Choose an appropriate time (no respiratory infection, patient not travelling, not pregnant).
• Approach each step as a therapeutic trial: engage the patient in the process, document their asthma status
(symptom control, lung function and risk factors, Box 2-2, p.38), provide clear instructions, provide a written
asthma action plan (Box 4-2, p.146) and ensure the patient has sufficient medication to resume their previous
dose if necessary, monitor symptoms and/or PEF, and schedule a follow-up visit (Evidence D).
• Stepping down ICS doses by 25–50% at 3 month intervals is feasible and safe for most patients (Evidence A).327

TE
Current Current medication
Options for stepping down Evidence
step and dose

U
IB
TR
Step 5 High-dose ICS-LABA plus • Optimize inhaled therapy and reduce OCS dose D
oral corticosteroids (OCS)

IS
• Use sputum-guided approach to reducing OCS B

D
• Alternate-day OCS treatment D

R
D

O
• Replace OCS with high-dose ICS

PY
• If T2 high severe asthma, add biologic therapy and reduce OCS A
O
C
High-dose ICS-LABA plus • Refer for expert advice D
T

other add-on agents

O
N

Step 4 Moderate- to high-dose ICS- • Continue combination ICS-LABA with 50% reduction in ICS component, by B
O
-D

LABA maintenance treatment using available formulations

• Discontinuing LABA may lead to deterioration328 A
L
IA

• Switch to maintenance and reliever therapy (MART) with ICS-formoterol, A

ER

with lower maintenance dose251

AT

Medium-dose ICS-formoterol* • D
M

Reduce maintenance ICS-formoterol* to low dose, and continue as-needed

D

as maintenance and reliever low-dose ICS-formoterol* reliever

TE

High-dose ICS plus second Reduce ICS dose by 50% and continue second controller327 B
H

•
IG

controller
R
PY

Step 3 Low-dose ICS-LABA • Reduce ICS-LABA to once daily D

O

maintenance • Discontinuing LABA may lead to deterioration328 A

C

Low-dose ICS-formoterol* as • Reduce maintenance ICS-formoterol* dose to once daily and continue C
maintenance and reliever as-needed low-dose ICS-formoterol* reliever
• Consider stepping down to as-needed-only low-dose ICS-formoterol D

Medium- or high-dose ICS • Reduce ICS dose by 50%327 A

• Adding LTRA† or LABA may allow ICS dose to be stepped down329 B

Step 2 Low-dose maintenance ICS • Once-daily dosing (budesonide, ciclesonide, mometasone)330,331 A

• Switch to as-needed low-dose ICS-formoterol 172,202,203,207 A
• Switch to taking ICS whenever SABA is taken215,216,218 217 B

Low-dose maintenance ICS • Switch to as-needed low-dose ICS formoterol171,172,202,203,207 A

or LTRA • Complete cessation of ICS in adults and adolescents is not advised as the A
risk of exacerbations is increased with SABA-only treatment207,326

See list of abbreviations (p.10). *MART: low-dose budesonide-formoterol or beclometasone-formoterol (p.80). †Note FDA warning about montelukast.236

3. Treating to control symptoms and minimize future risk 83

OTHER STRATEGIES FOR ADJUSTING ASTHMA TREATMENT
Some alternative strategies for adjusting asthma maintenance ICS-containing treatment have been evaluated:
• Treatment guided by sputum eosinophil count: in adults, this approach, when compared with guidelines-based
treatment, leads to a reduced risk of exacerbations and similar levels of symptom control and lung function in
patients with frequent exacerbations and moderate-severe asthma.305 However, only a limited number of centers
have routine access to induced sputum analysis. There are insufficient data available in children to assess this
approach.305 Sputum-guided treatment is recommended for adult patients with moderate or severe asthma who
are managed in (or can be referred to) centers experienced in this technique159,305 (Evidence A).
• Treatment guided by fractional concentration of exhaled nitric oxide (FeNO): In several studies of FeNO-guided
treatment, problems with the design of the intervention and/or control algorithms make comparisons and
conclusions difficult.332 Results of FeNO measurement at a single point in time should be interpreted with caution
(see p.28).44,199 In a 2016 meta-analysis, FeNO-guided treatment in children and young adults with asthma was
associated with a significant reduction in the number of patients with ≥1 exacerbation (OR 0.67; 95% CI 0.51–

TE
0.90) and in exacerbation rate (mean difference –0.27; 95% –0.49 to –0.06 per year) compared with guidelines-

U
based treatment333 (Evidence A); similar differences were seen in comparisons between FeNO-guided treatment

IB
and non-guidelines-based algorithms.333 However, a subsequent good-quality multicenter clinical trial in children

TR
with asthma in secondary and primary care centers found that the addition of FeNO to symptom-guided treatment

IS
D
did not reduce severe exacerbations over 12 months.334 In non-smoking adults with asthma, no significant

R
reduction in risk of exacerbations and in exacerbation rates was observed with FeNO-guided treatment, compared

O
with a treatment strategy similar to that in most guidelines; a difference was seen only in studies with other (non-
PY
typical) comparator approaches to adjustment of treatment.335 In adults and in children, no significant differences
O
C
were seen in symptoms or ICS dose with FeNO-guided treatment compared with other strategies.333,335
T
O

Further studies are needed to identify the populations most likely to benefit from sputum-guided305 or FeNO-guided
N

adjustment of maintenance ICS-containing treatment,333,335 and the optimal frequency of monitoring.

O
-D

There is a need for further evidence-based corticosteroid de-escalation strategies in patients with asthma. In a
L
IA

randomized controlled trial (RCT) of patients taking high-dose ICS-LABA, a strategy based on a composite of Type 2
ER

biomarkers only versus an algorithm based on ACQ-7 and history of recent exacerbation was inconclusive because a
AT

substantial proportion of patients did not follow recommendations for treatment change.336 Until more definitive evidence
M

for a specific strategy is available, GINA continues to recommend a clinical evaluation that includes patient-reported
D

symptoms as well as modifiable risk factors, comorbidities and patient preferences when making treatment decisions.
TE

Further evidence on the role of biomarkers in such decisions in Steps 1–4 is needed.
H
IG

The assessment of patients with severe asthma includes identification of the inflammatory phenotype, based on blood or
R
PY

sputum eosinophils or FeNO, to assess the patient’s eligibility for various add-on treatments including biologic therapy. A
O

higher baseline blood eosinophil count and/or FeNO predicts a good asthma response to some biologic therapies (see
C

Box 3-27 (p.124) and Box 3-28 (p.125).

TREATING OTHER MODIFIABLE RISK FACTORS

Some patients continue to experience exacerbations even with maximal doses of current treatment. Having even one
exacerbation increases the risk that a patient will have another within the next 12 months.122 There is increasing
research interest in identifying at-risk patients (Box 2-2B, p.38), and in investigating new strategies to further reduce
exacerbation risk.
In clinical practice, exacerbation risk can be reduced both by optimizing asthma medications, and by identifying and
treating modifiable risk factors (Box 3-17). Not all risk factors require or respond to a step up in controller treatment.

84 3. Treating to control symptoms and minimize future risk

 Box 3-17. Treating potentially modifiable risk factors to reduce exacerbations

Risk factor Treatment strategy Evidence

Any patient with ≥1 risk • Ensure patient is prescribed an ICS-containing treatment. A
factor for exacerbations • Switch to a regimen with an anti-inflammatory reliever (ICS-formoterol or ICS- A
(including poor SABA) if available, as this reduces the risk of severe exacerbations compared
symptom control)
with if the reliever is SABA. A
• Ensure patient has a written action plan appropriate for their health literacy. A
• Review patient more frequently than low-risk patients. A
• Check inhaler technique and adherence frequently; correct as needed. D
• Identify any modifiable risk factors (Box 2-2, p.38).
≥1 severe exacerbation • Switch to a regimen with an anti-inflammatory reliever (as-needed ICS- A
in last year formoterol or ICS-SABA) if available, as this reduces the risk of severe

TE
exacerbations compared with if the reliever is SABA. A

U
• Consider stepping up treatment if no modifiable risk factors. C

IB
• Identify any avoidable triggers for exacerbations.

TR
IS
Exposure to tobacco • Encourage smoking cessation by patient/family; provide advice and resources. A

D
smoke or e-cigarettes • Consider higher dose of ICS if asthma poorly controlled. B

R
O
Low FEV1, especially • Consider trial of 3 months’ treatment with high-dose ICS. B

PY
if <60% predicted • Consider 2 weeks’ OCS, but take short- and long-term risks into account
O B
D
C
• Exclude other lung disease, e.g., COPD.
T

• Refer for expert advice if no improvement. D

O
N

Obesity • Strategies for weight reduction B

O
-D

• Distinguish asthma symptoms from symptoms due to deconditioning, D

mechanical restriction, and/or sleep apnea.
L
IA
ER

Major psychological • Arrange mental health assessment. D

problems D
AT

• Help patient to distinguish between symptoms of anxiety and asthma; provide

M

advice about management of panic attacks.

D

Major socioeconomic • Identify most cost-effective ICS-based regimen. D

TE

problem
H
IG

Confirmed food allergy • Appropriate food avoidance; anaphylaxis action plan; injectable epinephrine; A
R

refer for expert advice.

PY
O

Occupational or • Remove from exposure as soon as possible. A

C

domestic exposure to • Refer for expert advice. D

irritants
Allergen exposure if • Consider trial of simple avoidance strategies; consider cost. C
sensitized • Consider step up of asthma treatment. D
• Consider adding SLIT in symptomatic adult HDM-sensitive patients with B
allergic rhinitis despite ICS, provided FEV1 is >70% predicted.
Sputum eosinophilia • Increase ICS dose, independent of level of symptom control. A*
despite medium/high
ICS (few centers)
See list of abbreviations (p.10). * Based on evidence from relatively small studies in selected populations. Also see Box 3-18 and p.88 for non-
pharmacological interventions.

3. Treating to control symptoms and minimize future risk 85

 Reduce the potential for local and/or systemic side-effects of medications by ensuring correct inhaler technique
(Box 3-22, p.100), by reminding patients to rinse and spit out after using ICS, and, after good asthma control has been
maintained for 3 months, by finding each patient’s minimum effective dose (the lowest dose that will maintain good
symptom control and minimize exacerbations, Box 3-16, p.83). Check for drug interactions particularly with cytochrome
P450 inhibitors (see p.40).

OTHER THERAPIES

Allergen immunotherapy
Allergen-specific immunotherapy may be a treatment option where allergy plays a prominent role, including asthma with
allergic rhinoconjunctivitis.337,338 There are currently two approaches: subcutaneous immunotherapy (SCIT) and
sublingual immunotherapy (SLIT). Few studies in asthma have compared immunotherapy with pharmacological therapy,
or used standardized outcomes such as exacerbations, and most studies have been in patients with mild asthma. The
allergens most commonly included in allergen immunotherapy studies have been house dust mite and grass pollens.

TE
There is insufficient evidence about safety and efficacy of allergen immunotherapy in patients sensitized to mold.339

U
IB
GINA is currently reviewing evidence about allergen immunotherapy for asthma, and will update its advice based on the

TR
findings.

IS
D
Subcutaneous immunotherapy (SCIT)

R
O
SCIT involves the identification and use of clinically relevant allergens, and administration of extracts in progressively

PY
higher doses to induce desensitization and/or tolerance. European physicians tend to favor single allergen
O
immunotherapy whereas Northern American physicians often prescribe multiple allergens for treatment.340 In people
C
T

with asthma and allergic sensitization, SCIT is associated with a reduction in symptom scores and medication
O
N

requirements, and improved allergen-specific and non-specific airway hyperresponsiveness.340

O
-D

For SCIT, analysis of pooled safety data from clinical trials and post-marketing surveillance in house dust mite allergic
respiratory disease suggests the incidence of adverse drug reactions is approximately 0.5%.341 Studies to date suggest
L
IA

that serious adverse effects of SCIT are uncommon, but may include life-threatening anaphylactic reactions.
ER
AT

Advice
M

• Compared with pharmacological and avoidance options, potential benefits of SCIT must be weighed against the risk
D

of adverse effects and the inconvenience and cost of the prolonged course of therapy, including the minimum half-
TE

hour wait required after each injection (Evidence D).

H
IG

Sublingual immunotherapy (SLIT)

R
PY

Modest effects were identified in a systematic review of SLIT for asthma in adults and children,338,342,343 but there was
O

concern about the design of many of the studies.344 The evidence for important outcomes such as exacerbations and
C

quality of life remains limited.344 There are few studies comparing SLIT with pharmacological therapy for asthma.345 A
trial of SLIT for house dust mites (HDM) in patients with asthma and HDM allergic rhinitis demonstrated a modest
reduction of ICS with high-dose SLIT.261 In another study in patients with asthma and HDM allergic rhinitis, SLIT added
to low or medium-dose ICS showed increased time to exacerbation during ICS reduction in suboptimally controlled
asthma.260
Side effects346-348 from SLIT for inhalant allergens are predominantly limited to oral and gastrointestinal symptoms.338
Advice
• For adult patients with allergic rhinitis and sensitized to house dust mite, with persisting asthma symptoms despite
low- to medium-dose ICS-containing therapy, consider adding SLIT, but only if FEV1 is >70% predicted (Evidence B)
• As for any treatment, potential benefits of SLIT for individual patients should be weighed against the risk of adverse
effects, and the cost to the patient and health system.

86 3. Treating to control symptoms and minimize future risk

Vaccinations
Influenza causes significant morbidity and mortality in the general population, and contributes to some acute asthma
exacerbations. In 2020, many countries saw a reduction in influenza-related illness, likely due to the handwashing,
masks and social/physical distancing introduced because of the COVID-19 pandemic.
The risk of influenza infection itself can be reduced by annual vaccination. A 2013 systematic review of placebo-
controlled randomized controlled trials of influenza vaccination showed no reduction in asthma exacerbations,349 but no
such studies had been performed since 2001. However, a later systematic review and meta-analysis that included
observational studies with a wide range of study designs suggested that influenza vaccination reduced the risk of
asthma exacerbations, although for most of the studies, bias could not be excluded.350 There is no evidence for an
increase in asthma exacerbations after influenza vaccination compared to placebo.350 A systematic review of studies in
individuals aged 2–49 years with mild–moderate asthma found no significant safety concerns or increased risk for
asthma-related outcomes after influenza vaccination with live attenuated virus.351
Other vaccines: People with asthma, particularly children and the elderly, are at higher risk of pneumococcal

TE
disease.352 There is insufficient evidence to recommend routine pneumococcal vaccination in all adults with asthma.353

U
IB
For information about COVID-19 vaccines, see p.111.

TR
Advice

IS
• Advise patients with moderate to severe asthma to receive an influenza vaccination every year, or at least when

D
R
vaccination of the general population is advised (Evidence C). Follow local immunization schedules.

O
• There is insufficient evidence to recommend routine pneumococcal or pertussis vaccination in adults with asthma.
Follow local immunization schedules. PY
O
C
• Advice about COVID-19 vaccination is on p.111.
T
O

• COVID-19 vaccination and influenza vaccination may be given on the same day.
N
O

Bronchial thermoplasty
-D
L

Bronchial thermoplasty is a potential treatment option at Step 5 in some countries for adult patients whose asthma
IA

remains uncontrolled despite optimized therapeutic regimens and referral to an asthma specialty center (Evidence B).
ER

Bronchial thermoplasty involves treatment of the airways during three separate bronchoscopies with a localized
AT

radiofrequency pulse.134 The treatment is associated with a large placebo effect.134 In patients taking high-dose ICS-
M
D

LABA, bronchial thermoplasty was associated with an increase in asthma exacerbations during the 3 month treatment
TE

period, and a subsequent decrease in exacerbations, but no beneficial effect on lung function or asthma symptoms
H

compared with sham-controlled patients.134 Extended follow-up of some treated patients reported a sustained reduction
IG
R

in exacerbations compared with pre-treatment.354 However, longer-term follow up of larger cohorts comparing
PY

effectiveness and safety, including for lung function, in both active and sham-treated patients is needed.
O
C

Advice
• For adult patients whose asthma remains uncontrolled despite optimization of asthma therapy and referral to a
severe asthma specialty center, and who do not have access to biologic therapy or are not eligible for it, bronchial
thermoplasty is a potential treatment option at Step 5 in some countries (Evidence B).
• Caution should be used in selecting patients for this procedure. The number of studies is small, people with chronic
sinus disease, frequent chest infections or FEV1 <60% predicted were excluded from the pivotal sham-controlled
study, and patients did not have their asthma treatment optimized before bronchial thermoplasty was performed.
• Bronchial thermoplasty should be performed in adults with severe asthma only in the context of an independent
Institutional Review Board-approved systematic registry or a clinical study, so that further evidence about
effectiveness and safety of the procedure can be accumulated.159

3. Treating to control symptoms and minimize future risk 87

Vitamin D
Several cross-sectional studies have shown that low serum levels of Vitamin D are linked to impaired lung function,
higher exacerbation frequency and reduced corticosteroid response.355 Vitamin D supplementation may reduce the rate
of asthma exacerbation requiring treatment with systemic corticosteroids or may improve symptom control in asthma
patients with baseline 25(OH)D of less than approximately 25–30 nmol/L.356,357 In a meta-analysis, benefit for worsening
asthma was seen in some studies, but to date, there is no good-quality evidence that Vitamin D supplementation leads
to improvement in asthma control or reduction in exacerbations.358-360 More studies are needed.

NON-PHARMACOLOGICAL STRATEGIES
In addition to pharmacological treatments, other strategies may be considered where relevant, to assist in improving
symptom control and/or reducing future risk. The advice and evidence level are summarized in Box 3-18, with brief text
on the following pages.

TE
U
IB
Box 3-18.Non-pharmacological interventions – summary

TR
Intervention Advice/recommendation (continued on next page) Evidence

IS
D
Cessation of • At every visit, strongly encourage people with asthma who smoke or vape to quit. Provide access A

R
O
smoking, to counseling and smoking cessation programs (if available).

PY
environmental
tobacco exposure • Advise parents/caregivers of children with asthma not to smoke and not to allow smoking in rooms
O A
or cars that their children use.
C
(ETS) and vaping
T
O

• Strongly encourage people with asthma to avoid environmental smoke exposure. B

N

D
O

• Assess smokers/ex-smokers for COPD or overlapping features of asthma and COPD

-D

(asthma+COPD, previously called asthma-COPD overlap or ACO, Chapter 5, p.159), as additional

treatment strategies may be required.
L
IA

Physical activity
ER

• Encourage people with asthma to engage in regular physical activity for its general health benefits. A
AT

• Provide advice about prevention of exercise-induced bronchoconstriction with regular ICS. A

M

• Provide advice about prevention of breakthrough exercise-induced bronchoconstriction with

D
TE

o warm-up before exercise A

H

o SABA (or ICS-SABA) before exercise A

IG
R

o low-dose ICS-formoterol before exercise (see Box 3-15, p.80). B

PY

• Regular physical activity improves cardiopulmonary fitness, and can have a small benefit for B
O
C

asthma control and lung function, including with swimming in young people with asthma.
• Physical activity interventions in adults with moderate/severe asthma was associated with A
improved symptoms and quality of life
• There is little evidence to recommend one form of physical activity over another. D
Avoidance of • Ask all patients with adult-onset asthma about their work history and other exposures to irritant D
occupational or gases or particles, including at home.
domestic
exposures to • In management of occupational asthma, identify and eliminate occupational sensitizers as soon as A
allergens or possible, and remove sensitized patients from any further exposure to these agents.
irritants • Patients with suspected or confirmed occupational asthma should be referred promptly for expert A
assessment and advice, if available.

88 3. Treating to control symptoms and minimize future risk

 Box 3-18 (continued) Non-pharmacological interventions – Summary

Intervention Advice/recommendation Evidence

Avoidance of • Always ask about asthma before prescribing NSAIDs, and advise patients to stop using them if D
medications that asthma worsens.
may make
asthma worse • Always ask people with asthma about concomitant medications. D

• Aspirin and NSAIDs (non-steroidal anti-inflammatory drugs) are not generally contraindicated A
unless there is a history of previous reactions to these agents (see p.117).
• Decide about prescription of oral or ophthalmic beta-blockers on a case-by-case basis. Initiate D
treatment under close medical supervision by a specialist.
• If cardioselective beta-blockers are indicated for acute coronary events, asthma is not an absolute D
contra-indication, but the relative risks/benefits should be considered.
Healthy diet

TE
• Encourage patients with asthma to consume a diet high in fruit and vegetables for its general A
health benefits.

U
IB
Avoidance of

TR
• Allergen avoidance is not recommended as a general strategy in asthma. A
indoor allergens

IS
• For sensitized patients, there is limited evidence of clinical benefit for asthma in most A

D
circumstances with single-strategy indoor allergen avoidance.

R
O
• Remediation of dampness or mold in homes reduces asthma symptoms and medication use in A
adults.
PY
O
C
• For patients sensitized to house dust mite and/or pets, there is limited evidence of clinical benefit B
T
O

for asthma with avoidance strategies (only in children) .

N
O

• Allergen avoidance strategies are often complicated and expensive, and there are no validated D
-D

methods for identifying those who are likely to benefit.

L

Weight reduction • Include weight reduction in the treatment plan for obese patients with asthma.
IA

B
ER

• For obese adults with asthma a weight reduction program plus twice-weekly aerobic and strength B
AT

exercises is more effective for symptom control than weight reduction alone.
M

Breathing • Breathing exercises may be a useful supplement to asthma pharmacotherapy for symptoms and A
D

exercises quality of life, but they do not reduce exacerbation risk or have consistent effects on lung function.
TE
H

Avoidance of • Encourage people with asthma to use non-polluting heating and cooking sources, and for sources B
IG

indoor air of pollutants to be vented outdoors where possible.

R
PY

pollution
O
C

Avoidance of • For sensitized patients, when pollen and mold counts are highest, closing windows and doors, D
outdoor allergens remaining indoors, and using air conditioning may reduce exposure to outdoor allergens.

Dealing with • Encourage patients to identify goals and strategies to deal with emotional stress if it makes their D
emotional stress asthma worse.
• There is insufficient evidence to support one stress-reduction strategy over another, but relaxation B
strategies and breathing exercises may be helpful.
• Arrange a mental health assessment for patients with symptoms of anxiety or depression. D

Addressing social • In US studies, comprehensive social risk interventions were associated with reduced emergency A
risk department visits and hospitalizations for children. Studies from other countries and settings are
needed.

3. Treating to control symptoms and minimize future risk 89

 Box 3-18 (continued) Non-pharmacological interventions – Summary

Intervention Advice/recommendation Evidence

Avoidance of • During unfavorable environmental conditions (very cold weather or high air pollution) it may be D
outdoor air helpful, if feasible, to stay indoors in a climate-controlled environment, and to avoid strenuous
pollutants/weather outdoor physical activity; and to avoid polluted environments during viral infections, if feasible.
conditions

Avoidance of • Food avoidance should not be recommended unless an allergy or food chemical sensitivity has D
foods and food been clearly demonstrated, usually by carefully supervised oral challenges.
chemicals • For patients with confirmed food allergy, refer for specialist advice if available D
• For patients with confirmed food allergy, food allergen avoidance may reduce asthma D
exacerbations.
• If food chemical sensitivity is confirmed, complete avoidance is not usually necessary, and D

TE
sensitivity often decreases when asthma control improves.

U
See list of abbreviations (p.10). Interventions with highest level evidence are shown first.

IB
TR
IS
D
R
Cessation of smoking and vaping and avoidance of environmental tobacco smoke

O
PY
Cigarette smoking has multiple deleterious effects in people with established asthma, in addition to its other well-known
O
effects such as increased risk of lung cancer, chronic obstructive pulmonary disease (COPD) and cardiovascular
C

disease; and, with exposure in pregnancy, increased risk of asthma and lower respiratory infections in children.
T
O
N

In people with asthma (children and adults), exposure to environmental tobacco smoke increases the risk of
O

hospitalization and poor asthma control. Active smoking is associated with increased risk of poor asthma control,
-D

hospital admissions and, in some studies, death from asthma; increased rate of decline of lung function and may lead to
L
IA

COPD; and reduced the effectiveness of inhaled and oral corticosteroids.361 After smoking cessation, lung function
ER

improves and airway inflammation decreases.362 Reduction of environmental tobacco smoke exposure improves asthma
AT

control and reduces hospital admissions in adults and children.363 Use of e-cigarettes (vaping) is associated with an
M

increased risk of asthma symptoms or diagnosis, and an increased risk of asthma exacerbations.108,364
D
TE

Advice
H

• At every visit, strongly encourage people with asthma who smoke to quit. They should be provided with access to
IG
R

counseling and, if available, to smoking cessation programs (Evidence A).

PY

• Strongly encourage people with asthma who vape to quit.

O

• Strongly encourage people with asthma to avoid environmental smoke exposure (Evidence B).
C

• Advise parents/caregivers of children with asthma not to smoke and not to allow smoking in rooms or cars that their
children use (Evidence A).
• Assess patients with a >10 pack-year smoking history for COPD or asthma–COPD overlap, as additional treatment
strategies may be required (see Chapter 5, p.159).

Physical activity
For people with asthma, as in the general population, regular moderate physical activity has important health benefits
including reduced cardiovascular risk and improved quality of life.365 There is some evidence that aerobic exercise
training can have a small beneficial effect on asthma symptom control and lung function, although not airway
inflammation.366 In physically inactive adults with moderate/severe asthma, physical activity interventions were
associated with reduced symptoms and improved quality of life.367 Further studies are needed to identify the optimal
regimen. Improved cardiopulmonary fitness may reduce the risk of dyspnea unrelated to airflow limitation being
mistakenly attributed to asthma. In one study of non-obese patients with asthma, high intensity interval training together

90 3. Treating to control symptoms and minimize future risk

 with a diet with high protein and low glycemic index improved asthma symptom control, although no benefit on lung
function was seen.368 In young people with asthma, swimming training is well tolerated and leads to increased lung
function and cardio-pulmonary fitness;369 however, there are some concerns about exposure to chlorine and
trichloramine with indoor pools.52
Exercise is an important cause of asthma symptoms for many asthma patients, but EIB can usually be reduced with
maintenance ICS.52 Breakthrough exercise-related symptoms can be managed with warm-up before exercise,52 and/or
by taking SABA52 or low-dose ICS-formoterol214 before or during exercise.
Advice
• Encourage people with asthma to engage in regular physical activity because of its general health benefits
(Evidence A). However, regular physical activity confers no specific benefit on lung function or asthma symptoms per
se, with the exception of swimming in young people with asthma (Evidence B). There is insufficient evidence to
recommend one form of physical activity over another (Evidence D).
• Provide patients with advice about prevention and management of exercise-induced bronchoconstriction including

TE
with daily treatment with ICS (Evidence A) plus SABA as-needed and pre-exercise (Evidence A), or treatment with

U
low-dose ICS-formoterol as-needed and before exercise (Evidence B), with warm-up before exercise if needed

IB
(Evidence A). For doses of ICS-formoterol, see Box 3-15, p.80. For patients prescribed as-needed ICS-SABA, this

TR
can also be used before exercise.

IS
D
R
Avoidance of occupational or domestic exposures

O
PY
Occupational exposures to allergens or sensitizers account for a substantial proportion of the incidence of adult-onset
O
asthma.370 Once a patient has become sensitized to an occupational allergen, the level of exposure necessary to induce
C

symptoms may be extremely low, and resulting exacerbations become increasingly severe. Attempts to reduce
T
O

occupational exposure have been successful, especially in industrial settings.49 Cost-effective minimization of latex
N
O

sensitization can be achieved by using non-powdered low-allergen gloves instead of powdered latex gloves.49
-D

Advice
L
IA

• Ask all patients with adult-onset asthma about their work history and other exposures to inhaled allergens or irritants,
ER

including at home (Evidence D).

AT

• In management of occupational asthma, identify and eliminate occupational sensitizers as soon as possible, and
M

remove sensitized patients from any further exposure to these agents (Evidence A).
D
TE

• Patients with suspected or confirmed occupational asthma should be referred for expert assessment and advice, if
H

available, because of the economic and legal implications of the diagnosis (Evidence A).
IG
R
PY

Avoidance of medications that may make asthma worse

O

Aspirin and other NSAIDs can cause severe exacerbations.371 Beta-blocker drugs, including topical ophthalmic
C

preparations, may cause bronchospasm372 and have been implicated in some asthma deaths. However, beta-blockers
have a proven benefit in the management of cardiovascular disease. People with asthma who have had an acute
coronary event and received beta-blockers within 24 hours of hospital admission have been found to have lower in-
hospital mortality rates than those who did not receive beta-blockers.373
Advice
• Always ask people with asthma about concomitant medications, including eyedrops (Evidence D).
• Always ask about asthma and previous reactions before prescribing NSAIDs, and advise patients to stop using these
medications if asthma worsens.
• Aspirin and NSAIDs are not generally contraindicated in asthma unless there is a history of previous reactions to
these agents (Evidence A). (See ‘Aspirin-exacerbated respiratory disease’, p.117).
• For people with asthma who may benefit from oral or ophthalmic beta-blocker treatment, a decision to prescribe
these medications should be made on a case-by-case basis, and treatment should only be initiated under close
medical supervision by a specialist (Evidence D).

3. Treating to control symptoms and minimize future risk 91

 • Asthma should not be regarded as an absolute contraindication to use cardioselective beta-blockers when they are
indicated for acute coronary events, but the relative risks and benefits should be considered (Evidence D). The
prescribing physician and patient should be aware of the risks and benefits of treatment.374

Avoidance of indoor allergens

Because many asthma patients react to multiple factors that are ubiquitous in the environment, avoiding these factors
completely is usually impractical and very burdensome for the patient. Medications to maintain good asthma control
have an important role because patients are often less affected by environmental factors when their asthma is well
controlled.
There is conflicting evidence about whether measures to reduce exposure to indoor allergens are effective at reducing
asthma symptoms.375,376 The majority of single interventions have failed to achieve a sufficient reduction in allergen load
to lead to clinical improvement.375,377,378 It is likely that no single intervention will achieve sufficient benefits to be cost
effective (Box 3-19, p.93). One study of insecticidal bait in homes eradicated cockroaches for a year and led to a

TE
significant decrease in symptoms, improvement in pulmonary function, and less health care use for children with

U
moderate to severe asthma.379

IB
TR
House dust mite: HDM live and thrive in many sites throughout the house, so they are difficult to reduce and impossible

IS
to eradicate. A systematic review of multi-component interventions to reduce allergens, including HDM, showed no

D
benefit for asthma in adults and a small benefit for children.380 One study that used a rigorously applied integrated

R
O
approach to HDM control led to a significant decrease in symptoms, medication use and improvement in pulmonary

PY
function for children with HDM sensitization and asthma.381 However, this approach is complicated and expensive and is
O
not generally recommended. A study in HDM-sensitized children recruited after emergency department presentation
C

showed a decrease in emergency department visits, but not oral corticosteroids, with the use of mite-impermeable
T
O

encasement of the mattress, pillow and duvet.382

N
O

Furred pets: complete avoidance of pet allergens is impossible for sensitized patients as these allergens are ubiquitous
-D

outside the home383 in schools,384 public transport, and even cat-free buildings, probably transferred on clothes.384
L
IA

Although removal of such animals from the home of a sensitized patient is encouraged,385 it can be many months before
ER

allergen levels decrease,386 and the clinical effectiveness of this and other interventions remains unproven.387
AT

Pest rodents: symptomatic patients suspected of domestic exposure to pest rodents should be evaluated with skin prick
M

tests or specific IgE, as exposure may not be apparent unless there is an obvious infestation.388 High-level evidence for
D
TE

the effectiveness of removing rodents is lacking, as most integrated pest management interventions also remove other
H

allergen sources;388 one non-sham-controlled study showed comparable clinical improvement with pest reduction
IG

education and integrated pest management.389

R
PY

Cockroaches: avoidance measures for cockroaches are only partially effective in removing residual allergens390 and
O
C

evidence of clinical benefit is lacking.

Fungi: fungal exposure has been associated with asthma exacerbations. The number of fungal spores can best be
reduced by removing or cleaning mold-laden objects.391 Air conditioners and dehumidifiers may be used to reduce
humidity to less than 50% and to filter large fungal spores. However, air conditioning and sealing of windows have also
been associated with increases in fungal and HDM allergens.392
Advice
• Allergen avoidance is not recommended as a general strategy for people with asthma (Evidence A).
• For sensitized patients, although it would seem logical to attempt to avoid allergen exposure in the home, there is
some evidence for clinical benefit with single avoidance strategies (Evidence A) and only limited evidence for benefit
with multi-component avoidance strategies (in children) (Evidence B).
• Although allergen avoidance strategies may be beneficial for some sensitized patients (Evidence B), they are often
complicated and expensive, and there are no validated methods for identifying those who are likely to benefit
(Evidence D).

92 3. Treating to control symptoms and minimize future risk

 Box 3-19. Effectiveness of avoidance measures for indoor allergens
Evidence of effect Evidence of clinical
Measure
on allergen levels benefit
House dust mites
Encase bedding in impermeable covers Some (A) Adults - none (A)
Children - some (A)
Wash bedding on hot cycle (55–60°C) Some (C) None (D)
Replace carpets with hard flooring Some (B) None (D)
Acaricides and/or tannic acid Weak (C) None (D)
Minimize objects that accumulate dust None (D) None (D)
Vacuum cleaners with integral HEPA filter and double- Weak (C) None (D)
thickness bags

TE
U
Remove, hot wash, or freeze soft toys None (D) None

IB
TR
Pets

IS
Remove cat/dog from the home Weak (C) None (D)

D
Keep pet from the main living areas/bedrooms Weak (C) None (D)

R
O
HEPA-filter air cleaners Some (B) None (A)
PY
O
Wash pet Weak (C) None (D)
C

Replace carpets with hard flooring None (D) None (D)

T
O
N

Vacuum cleaners with integral HEPA filter and double- None (D) None (D)
O

thickness bags
-D

Cockroaches
L
IA

Bait plus professional extermination of cockroaches Minimal (D) None (D)

ER

Baits placed in households Some (B) Some (B)

AT
M

Rodents
D

Integrated pest management strategies Some (B) Some (B)

TE
H

Fungi
IG

Remediation of dampness or mold in homes A A

R
PY

Air filters, air conditioning Some (B) None (D)

O
C

See list of abbreviations (p.10). This table is adapted from Custovic et al393

Healthy diet
In the general population, a diet high in fresh fruit and vegetables has many health benefits, including prevention of
many chronic diseases and forms of cancer. Many epidemiological studies report that a high fruit and vegetable diet is
associated with a lower risk of asthma and lung function decline. There is some evidence that increasing fruit and
vegetable intake leads to an improvement in asthma control and a reduced risk of exacerbations.394
Advice
• Encourage patients with asthma to consume a diet high in fruit and vegetables for its general health benefits
(Evidence A).

3. Treating to control symptoms and minimize future risk 93

Weight reduction for obese patients
Asthma can be more difficult to control in obese patients,395-397 the risk of exacerbations is greater,103,104 and response to
ICS may be reduced.398 There is limited evidence about the effect of weight loss on asthma control. Studies have
ranged from dietary restriction to multifactorial interventions with exercise training and cognitive behavioral therapy, but
populations have generally been small, and interventions and results have been heterogeneous.399 In some studies,
weight loss has improved asthma control, lung function and health status, and reduced medication needs in obese
patients with asthma.400,401 The most striking results have been observed after bariatric surgery,402,403 but even 5–10%
weight loss with diet, with or without exercise, can lead to improved asthma control and quality of life.404
Advice
• Include weight reduction in the treatment plan for obese patients with asthma (Evidence B). Increased exercise alone
appears to be insufficient (Evidence B).

Breathing exercises

TE
A systematic review of studies of breathing and/or relaxation exercises in adults with asthma and/or dysfunctional

U
breathing, including the Buteyko method and the Papworth method, reported improvements in symptoms, quality of life

IB
TR
and/or psychological measures, but with no consistent effect on lung function and no reduction in risk of

IS
exacerbations.405

D
R
Studies of non-pharmacological strategies, such as breathing exercises, can only be considered high quality when

O
control groups are appropriately matched for level of contact with health professionals and for asthma education. A
PY
study of two physiologically contrasting breathing exercises, which were matched for contact with health professionals
O
C
and instructions about rescue inhaler use, showed similar improvements in reliever use and ICS dose after down-
T

titration in both groups.406 This suggests that perceived improvement with breathing exercises may be largely due to
O
N

factors such as relaxation, voluntary reduction in use of rescue medication, or engagement of the patient in their care.
O

The cost of some commercial programs may be a potential limitation.

-D
L

Breathing exercises used in some of these studies are available at www.breathestudy.co.uk407 and
IA

www.woolcock.org.au/resources/breathing-techniques-asthma.406
ER
AT

Advice
M

• Breathing exercises may be considered as a supplement to conventional asthma management strategies for
D

symptoms and quality of life, but they do not improve lung function or reduce exacerbation risk (Evidence A).
TE
H
IG

Avoidance of indoor air pollution

R
PY

In addition to passive and active smoking, other major indoor air pollutants that are known to impact on respiratory
O

health include nitric oxide, nitrogen oxides, carbon monoxide, carbon dioxide, sulfur dioxide, formaldehyde, and
C

biologicals (endotoxin).408,409 Sources include cooking and heating devices using gas and solid biomass fuels,
particularly if they are not externally flued (vented). Installation of non-polluting, more effective heating (heat pump, wood
pellet burner, flued gas) in the homes of children with asthma does not significantly improve lung function but
significantly reduces symptoms of asthma, days off school, healthcare utilization, and pharmacist visits.410 Air filters can
reduce fine particle exposure, but there is no consistent effect on asthma outcomes.411,412
Advice
• Encourage people with asthma to use non-polluting heating and cooking sources, and for sources of pollutants to be
vented outdoors where possible (Evidence B).

94 3. Treating to control symptoms and minimize future risk

Strategies for dealing with emotional stress
Emotional stress may lead to asthma exacerbations in children413 and adults. Hyperventilation associated with laughing,
crying, anger, or fear can cause airway narrowing.414,415 Panic attacks have a similar effect.416,417 However, it is
important to note that asthma is not primarily a psychosomatic disorder. During stressful times, medication adherence
may also decrease.
Advice
• Encourage patients to identify goals and strategies to deal with emotional stress if it makes their asthma worse
(Evidence D).
• There is insufficient evidence to support one strategy over another, but relaxation strategies and breathing exercises
may be helpful in reducing asthma symptoms (Evidence B).
• Arrange a mental health assessment for patients with symptoms of anxiety or depression (Evidence D).

Interventions addressing social risks

TE
A systematic review of social risk intervention studies based in the USA found that interventions that addressed these

U
IB
challenges, including health and health care, neighborhood and built environment, and social and community context,

TR
were associated with a marked reduction in pediatric emergency department visits and hospitalizations for asthma.418

IS
Data are needed from studies in other countries and other socioeconomic settings.

D
R
O
Avoidance of outdoor allergens

PY
For patients sensitized to outdoor allergens such as pollens and molds, these are impossible to avoid completely.
O
C

Advice
T
O

• For sensitized patients, closing windows and doors, remaining indoors when pollen and mold counts are highest, and
N

using air conditioning may reduce exposure (Evidence D).

O
-D

• The impact of providing information in the media about outdoor allergen levels is difficult to assess.
L
IA

Avoidance of outdoor air pollution

ER
AT

Meta-analysis of epidemiological studies showed a significant association between air pollutants such as ozone,
M

nitrogen oxides, acidic aerosols, and particulate matter and symptoms or exacerbations of asthma, including emergency
D

department visits and hospitalizations.110 Use of digital monitoring identified a lag of 0–3 days between higher levels of
TE

multiple pollutants and increased asthma medication use.112 Proximity to main roads at home and school is associated
H
IG

with greater asthma morbidity.419 Certain weather and atmospheric conditions like thunderstorms420,421 may trigger
R

asthma exacerbations by a variety of mechanisms, including dust and pollution, by increasing the level of respirable
PY

allergens, and causing changes in temperature and/or humidity. Reduction of outdoor air pollutants usually requires
O
C

national or local policy changes. For example, short-term traffic restrictions imposed in Beijing during the 2008 Olympics
reduced pollution and was associated with a significant fall in asthma outpatient visits.422
Advice
• In general, when asthma is well controlled, there is no need for patients to modify their lifestyle to avoid unfavorable
outdoor conditions (air pollutants, weather).
• It may be helpful, where possible, during unfavorable environmental conditions (very cold weather, low humidity or
high air pollution) to avoid strenuous outdoor physical activity and stay indoors in a climate-controlled environment;
and to avoid polluted environments during viral infections (Evidence D).

3. Treating to control symptoms and minimize future risk 95

Avoidance of food and food chemicals
Food allergy as an exacerbating factor for asthma is uncommon and occurs primarily in young children. Confirmed food
allergy is a risk factor for asthma-related mortality.105
Food chemicals, either naturally occurring or added during processing, may also trigger asthma symptoms especially
when asthma is poorly controlled. Sulfites (common food and drug preservatives found in such foods as processed
potatoes, shrimp, dried fruits, beer, and wine) have often been implicated in causing severe asthma exacerbations.423
However, the likelihood of a reaction is dependent on the nature of the food, the level and form of residual sulfite, the
sensitivity of the patient, and the mechanism of the sulfite-induced reaction.423 There is little evidence to support any
general role for other dietary substances including benzoate, the yellow dye, tartrazine, and monosodium glutamate in
worsening asthma.
Advice
• Ask people with asthma about symptoms associated with any specific foods (Evidence D).
• Food avoidance should not be recommended unless an allergy or food chemical sensitivity has been clearly

TE
demonstrated (Evidence D), usually by carefully supervised oral challenges.105

U
IB
• Patients with suspected or confirmed food allergy should be referred for expert advice about management of asthma

TR
and anaphylaxis (Evidence D)

IS
• If food allergy is confirmed, food allergen avoidance can reduce asthma exacerbations (Evidence D).

D
• If food chemical sensitivity is confirmed, complete avoidance is not usually necessary, and sensitivity often

R
O
decreases when overall asthma control improves (Evidence D).

PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

96 3. Treating to control symptoms and minimize future risk

INDICATIONS FOR REFERRAL FOR EXPERT ADVICE
For most patients asthma can usually be managed in primary care, but some clinical situations warrant referral for
expert advice regarding diagnosis and/or management (Box 3-20). This list is based on consensus. Indications for
referral may vary, because the level at which asthma care is mainly delivered (primary care or specialist care) varies
substantially between countries.

Box 3-20. Indications for considering referral for expert advice, where available

Difficulty confirming the diagnosis of asthma

• Patient has symptoms of chronic infection, or features suggesting a cardiac or other non-pulmonary cause
(Box 1-3, p.28) (immediate referral recommended).
• Diagnosis is unclear, even after a trial of therapy with ICS or systemic corticosteroids.
• Patient has features of both asthma and COPD, and there is doubt about priorities for treatment.

TE
Suspected occupational asthma

U
IB
• Refer for confirmatory testing and identification of sensitizing or irritant agent, and specific advice about eliminating

TR
exposure and pharmacological treatment. See specific guidelines49 for details.

IS
D
Persistent or severely uncontrolled asthma or frequent exacerbations

R
O
• Symptoms remain uncontrolled, or patient has ongoing exacerbations or low lung function despite correct inhaler
PY
technique and good adherence with Step 4 treatment (medium-dose ICS-LABA, Box 3-12, p.65). Before referral,
O
depending on the clinical context, identify and treat modifiable risk factors (Box 2-2, p.38; Box 3-17, p.85) and
C

comorbidities (p.106).
T
O

• Patient frequently uses asthma-related health care (e.g., multiple ED visits or urgent primary care visits).
N
O

• See Section 3.5 (p.120) on difficult-to-treat and severe asthma, including a decision tree.
-D

Any risk factors for asthma-related death (see Box 4-1, p.141)
L
IA
ER

• Near-fatal asthma attack (ICU admission, or mechanical ventilation for asthma) at any time in the past
AT

• Suspected or confirmed anaphylaxis or food allergy in a patient with asthma

M

Evidence of, or risk of, significant treatment side-effects

D
TE

• Significant side-effects from treatment

H
IG

• Need for long-term oral corticosteroid use

R
PY

• Frequent courses of oral corticosteroids (e.g., two or more courses a year)

O
C

Symptoms suggesting complications or sub-types of asthma

• e.g., aspirin-exacerbated respiratory disease (p.117); allergic bronchopulmonary aspergillosis

Additional reasons for referral in children 6–11 years

• Doubts about diagnosis of asthma e.g., respiratory symptoms are not responding well to treatment in a child who
was born prematurely
• Symptoms or exacerbations that remain uncontrolled despite medium-dose ICS (Box 3-14B, p.67) with correct
inhaler technique and good adherence
• Suspected side-effects of treatment (e.g., growth delay)
• Concerns about the child’s welfare or well-being
See list of abbreviations (p.10). For indications for referral in children 0-5 years, see p.176.

3. Treating to control symptoms and minimize future risk 97

3.3. GUIDED ASTHMA SELF-MANAGEMENT EDUCATION AND SKILLS TRAINING

KEY POINTS

• As with other chronic diseases, people with asthma need education and skills training to manage it well. This is
most effectively achieved through a partnership between the patient and their health care providers. The essential
components for this include:
o Choosing the most appropriate inhaler for the patient’s asthma treatment: consider available devices, cost, the
ability of the patient to use the inhaler after training, environmental impact, and patient satisfaction
o Skills training to use inhaler devices effectively
o Encouraging adherence with medications, appointments and other advice, within an agreed management
strategy
o Asthma information

TE
o Training in guided self-management, with self-monitoring of symptoms or peak flow; a written asthma action

U
plan to show how to recognize and respond to worsening asthma; and regular review by a health care provider

IB
or trained health care worker.

TR
IS
• In developing, customizing and evaluating self-management interventions for different cultures, sociocultural factors

D
should be taken into account.424

R
O
PY
SKILLS TRAINING FOR EFFECTIVE USE OF INHALER DEVICES O
C
Delivery of respiratory medications by inhalation achieves a high concentration in the airways, more rapid onset of
T

action, and fewer systemic adverse effects than systemic delivery. However, using an inhaler is a skill that must be
O
N

learnt and maintained in order for the medication to be delivered effectively.

O
-D

Poor inhaler technique leads to poor asthma control, increased risk of exacerbations and increased adverse effects.102
L

Most patients (up to 70–80%) do not use their inhaler correctly. Unfortunately, many health care providers are unable to
IA

correctly demonstrate how to use the inhalers they prescribe.425 Most people with incorrect technique are unaware that
ER

they have a problem. There is no ‘perfect’ inhaler – patients can have problems using any inhaler device. The several
AT

factors that should be considered in the choice of inhaler device for an individual patient are described below and in Box
M

3-21 (p.99).
D
TE

Strategies for ensuring effective use of inhaler devices are summarized in Box 3-22, p.100.426 These principles apply to
H
IG

all types of inhaler devices. For patients prescribed pressurized metered dose inhalers (pMDIs), use of a spacer
R

improves delivery and (for ICS) reduces the potential for local side-effects such as dysphonia and oral candidiasis.427
PY

With ICS, the risk of candidiasis can also be reduced by rinsing and spitting out after use.
O
C

Checking and correcting inhaler technique using a standardized checklist takes only 2–3 minutes and leads to improved
asthma control in adults428,429 and older children426 (Evidence A). A physical demonstration is essential to improve
inhaler technique.430 This is easiest if the health care provider has placebo inhalers and a spacer. After training, inhaler
technique deteriorates with time, so checking and re-training must be repeated regularly. This is particularly important
for patients with poor symptom control or a history of exacerbations. Attaching a pictogram431,432 or a list of inhaler
technique steps433 to the inhaler substantially increases the retention of correct technique at follow-up. Pharmacists,
nurses and trained lay health workers can provide highly effective inhaler skills training.426,434-436

SHARED DECISION-MAKING FOR CHOICE OF INHALER DEVICE

Globally, multiple different devices are available for delivery of inhaled medication, including pressurized metered-doses
inhalers (pMDIs), dry-powder inhalers (DPIs), mist inhalers and nebulizers, although the choice of inhaler device for
each medication class in any country is often limited. Reducing the risk of severe exacerbations and asthma deaths is a
global priority that is driving initiatives to increase access to ICS-containing inhalers for people with asthma worldwide
(see p.112) and, when these inhalers are available, to ensure that patients are trained in how to use them correctly.

98 3. Treating to control symptoms and minimize future risk

 There is also increasing interest in the potential to reduce the impact of asthma and its care (routine and urgent) on the
environment, including from the manufacture and potential recycling of inhaler devices, and from the propellants in
pMDIs, which are the inhalers most commonly used worldwide.437-439
For all age-groups, selecting the right inhaler for the individual patient is crucial to asthma care, not only to reduce
patients’ symptom burden, but also to reduce the need for emergency healthcare and hospitalization, which have even
greater environmental impacts than use of pMDIs.440,441

Box 3-21. Shared decision-making between health professional and patient about choice of inhalers

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10).

3. Treating to control symptoms and minimize future risk 99

 Box 3-22. Choice and effective use of inhaler devices
CHOOSE

• Choose the most appropriate inhaler device for the patient before prescribing. Consider the preferred medication
(Box 3-12, p.65; 3-13, p.66), available devices, patient skills, environmental impact and cost (see Box 3-22, p.100).
• If different options are available, encourage the patient to participate in the choice.
• For pMDIs, use of a spacer improves delivery and (with ICS) reduces the potential for side-effects.
• Ensure that there are no physical barriers, e.g. arthritis, that limit use of the inhaler.
• Avoid use of multiple different inhaler types where possible, to avoid confusion.
CHECK

• Check inhaler technique at every opportunity.

TE
• Ask the patient to show you how they use their inhaler (don’t just ask if they know how to use it).

U
• Identify any errors using a device-specific checklist.

IB
TR
CORRECT

IS
D
• Show the patient how to use the device correctly with a physical demonstration, e.g., using a placebo inhaler.

R
O
• Check technique again, paying attention to problematic steps. You may need to repeat this process 2–3 times

PY
within the same session for the patient to master the correct technique.428
O
• Consider an alternative device only if the patient cannot use the inhaler correctly after several repeats of training.
C
T

• Re-check inhaler technique frequently. After initial training, errors often recur within 4–6 weeks.442
O
N
O

CONFIRM
-D

• Clinicians should be able to demonstrate correct technique for each of the inhalers they prescribe.
L
IA

• Pharmacists and nurses can provide highly effective inhaler skills training.434,435
ER

See list of abbreviations (p.10).

AT
M

Several factors must be considered in shared decision-making about the choice of inhaler device for the individual patient
D

(Box 3-21, p.99), starting with the choice of the medication itself.
TE
H
IG

• Which medication class(es) or individual medication(s) does the patient need to relieve and control symptoms and
R

to prevent asthma exacerbations? The approach in GINA Track 1 (Box 3-5, p.58) is preferred, because the use of
PY

ICS-formoterol as an anti-inflammatory reliever reduces the risk of severe exacerbations and urgent health care
O

utilization compared with using a SABA reliever. The Track 1 approach also avoids the risks associated with
C

SABA over-use, and allows simple adjustment across treatment steps with a single medication for both symptom
relief and delivery of ICS-containing treatment. Most studies of MART with ICS-formoterol, and all studies of as-
needed-only ICS-formoterol have used a DPI.
• Which inhaler devices are available to the patient for these medications? The choice of device for any particular
medication class in an individual country is often limited. Consider local availability, access, and cost to the
patient. Where more than one medication is needed, a single (combination) inhaler is preferable to multiple
inhalers. Also consider the patient’s age, since DPIs are not suitable for most children aged ≤5 years and some
elderly patients; pMDIs with spacers remain essential for such patients.
• Can the patient use the available device(s) correctly after training? This may be determined by factors including
physical dexterity, coordination, inspiratory flow, and cognitive status. Different inhaler types require different
inhalation techniques, so it is preferable to avoid prescribing a pMDI and DPI for the same patient. Incorrect
inhaler technique increases risk of severe asthma exacerbations.

100 3. Treating to control symptoms and minimize future risk

 • What are the environmental implications of the available inhaler(s)? This has become an important part of inhaler
selection, particularly with regard to the propellants in pMDIs, but also related to inhaler manufacture and potential
recycling. However, clinicians need to be aware of the potential to place an additional burden on patients of so-
called ‘green guilt’, which could impact negatively on adherence and increase the risk of exacerbations.
• Is the patient satisfied with the medication and inhaler? The best inhaler for each patient is likely to be the one that
they prefer and are able to use, as this promotes adherence and reduces risk of exacerbations and adverse
effects.
• In follow-up, review symptom control, asthma exacerbations and adverse events, and check the patient’s ability to
use their inhaler(s) correctly, ideally at each visit.

ADHERENCE WITH MEDICATIONS AND WITH OTHER ADVICE

Identifying poor adherence

TE
Poor adherence is defined as the failure of treatment to be taken as agreed upon by the patient and the health care

U
provider. There is increasing awareness of the importance of poor adherence in chronic diseases, and of the potential to

IB
develop interventions to improve adherence.443 Approximately 50% of adults and children on long-term therapy for

TR
asthma fail to take medications as directed at least part of the time.174

IS
D
In clinical practice, poor adherence may be identified by an empathic question that acknowledges the likelihood of

R
O
incomplete adherence and encourages an open discussion. See Box 3-23, p.102 for examples. Checking the date of the

PY
last prescription or the date on the inhaler may assist in identifying poor adherence. In some health systems,
O
pharmacists can assist in identifying poorly adherent patients by monitoring dispensing records. Electronic inhaler
C

monitoring has also been used in clinical practice to identify poor adherence in patients with difficult-to-treat
T
O

asthma.160,161
N
O

In clinical studies, poor adherence may be identified by short adherence behavior questionnaires, or from dispensing
-D

records; dose or pill counting; electronic inhaler monitoring;444 and drug assay such as for prednisolone.445
L
IA
ER

Factors contributing to poor adherence

AT

It is important to elicit patients’ beliefs and concerns about asthma and asthma medications in order to understand the
M

reasons behind their medication-taking behavior. Factors involved in poor adherence are listed in Box 3-23, p.102. They
D
TE

include both intentional and unintentional factors. Issues such as ethnicity,446 health literacy,447,448 and numeracy185 are
H

often overlooked. Patients may be concerned about known side-effects or about perceived harm.318,449
IG
R
PY

Interventions that improve adherence in asthma

O

Few adherence interventions have been studied comprehensively in asthma. Some examples of successful
C

interventions have been published:

• Shared decision-making for medication/dose choice improved adherence and asthma outcomes.176,179
• Electronic inhaler reminders, either proactively or for missed doses, improved adherence450-452 and possibly
reduced exacerbations and oral corticosteroid use.450-453
• In a difficult inner-city environment, home visits for a comprehensive asthma program by an asthma nurse led to
improved adherence and reduced prednisone courses over the following several months.454
• Providing adherence information to clinicians did not improve ICS use among patients with asthma unless
clinicians chose to view the details of their patients’ medication use.455
• In a health maintenance organization, an automated voice recognition program with messages triggered when
refills were due or overdue led to improved ICS adherence relative to usual care, but no difference in urgent
care visits.456
• In one study, directly observed administration of maintenance asthma treatment at school, combined with
telemedicine oversight, was associated with more symptom-free days and fewer urgent visits than usual care.457

3. Treating to control symptoms and minimize future risk 101

 Digital interventions for adherence: A 2022 Cochrane review found that a variety of digital intervention strategies
improved adherence to maintenance controller medications, especially in those with poor adherence, reduced
exacerbations, and improved asthma control, in studies of up to 2 years’ duration in adults and children.453 Electronic
monitoring of maintenance inhaler use and text messages sent to phones appear to be effective. No harms associated
with these technologies were reported. The effects of digital interventions on quality of life, lung function and
unscheduled health care utilization are unclear.
Improving adherence to maintenance ICS-containing medications may not necessarily translate to improved clinical
outcomes.458 Further studies are needed of adherence strategies that are feasible for implementation in primary care.

Box 3-23. Poor adherence with prescribed maintenance treatment in asthma

Factors contributing to poor adherence How to identify poor adherence in clinical practice

Medication/regimen factors For patients prescribed maintenance treatment, ask an

TE
• Difficulties using inhaler device (e.g., arthritis) empathic question

U
IB
• Burdensome regimen (e.g., multiple times per • Acknowledge the likelihood of incomplete adherence and

TR
day) encourage an open non-judgmental discussion.

IS
• Multiple different inhalers Examples are:

D
‘Many patients don’t use their inhaler as prescribed.

R
Unintentional poor adherence

O
In the last 4 weeks, how many days a week have you been

PY
• Misunderstanding about instructions taking it – not at all, 1, 2, 3 or more days a week?’459
O
• Forgetfulness ‘Do you find it easier to remember your inhaler in the morning
C

• Absence of a daily routine or the evening?’

T
O

• Cost
N

Check medication usage

O

Intentional poor adherence • Check the date of the last prescription

-D

• Perception that treatment is not necessary • Check the date and dose counter on the inhaler
L
IA

• Denial or anger about asthma or its treatment • In some health systems, prescribing and dispensing
ER

• Inappropriate expectations frequency can be monitored electronically by clinicians

AT

• Concerns about side-effects (real or perceived) and/or pharmacists

M

• Dissatisfaction with health care providers • See review articles for more detail.173,460
D
TE

• Stigmatization
H

• Cultural or religious issues

IG
R

• Cost
PY
O

Examples of successful adherence interventions

C

• Shared decision-making for medication/dose choice176,179

• Inhaler reminders, either proactively or for missed doses450-452
• Prescribing low-dose ICS once-daily versus twice-daily461
• Home visits for a comprehensive asthma program by an asthma nurse454

ASTHMA INFORMATION
While education is relevant to asthma patients of all ages, the information and skills training required by each person
may vary, as will their ability or willingness to take responsibility. All individuals will require certain core information and
skills, but most education must be personalized and provided over several sessions or stages.
For young children, the focus of asthma education will be on the parent/caregiver, but young children can be taught
simple asthma management skills. Adolescents may have unique difficulties with adherence, and peer support group
education may help in addition to education provided by the health care provider.462 These are complex interventions,

102 3. Treating to control symptoms and minimize future risk

 and there have been few studies. Regional issues and the adolescent’s developmental stage may affect the outcomes
of such programs.463
The key features and components of an asthma education program are provided in Box 3-24. Information alone
improves knowledge but does not improve asthma outcomes.464 Social and psychological support may also be required
to maintain positive behavioral change, and skills are required for effective medication delivery. At the initial consultation,
verbal information should be supplemented with written or pictorial465,466 information about asthma and its treatment. The
GINA website (www.ginasthma.org) contains patient educational materials as well as links to several asthma websites.
Patients and their families should be encouraged to make a note of any questions that arise from reading this
information or as a result of the consultation, and should be given time to address these during the next consultation.
Asthma education and training, for both adults and children, can be delivered effectively by a range of health care
providers including pharmacists and nurses (Evidence A).434,435,467,468 Trained lay health workers (also known as
community health workers) can deliver discrete areas of respiratory care such as asthma self-management education.
Asthma education by trained lay health workers has been found to improve patient outcomes and healthcare utilization

TE
compared with usual care,436,469 and to a similar extent as nurse-led education in primary care470 (Evidence B). These

U
findings suggest the need for additional studies to assess applicability in other settings and populations.

IB
TR
IS
Box 3-24. Asthma information

D
R
O
Goal: To provide the person with asthma, their family and other carers with suitable information and training to manage

PY
their asthma in partnership with their health care providers C
O
Approach Content
T
O
N

• Focus on the development of the partnership. • Asthma diagnosis

O
-D

• Accept that this is a continuing process. • Rationale for treatment, and differences between
relievers and maintenance treatments (if prescribed)
L

• Share information.
IA
ER

• Potential side-effects of medications

• Adapt the approach to the patient’s level of health
AT

literacy (Box 3-1, p.49). • Prevention of symptoms and flare-ups: importance of

M

anti-inflammatory treatment
• Fully discuss expectations, fears and concerns.
D
TE

• How to recognize worsening asthma and what actions

• Develop shared goals.
H

to take; how and when to seek medical attention

IG
R

• Management of comorbidities
PY
O
C

TRAINING IN GUIDED ASTHMA SELF-MANAGEMENT

Guided self-management may involve varying degrees of independence, ranging broadly from patient-directed self-
management to doctor-directed self-management. With patient-directed self-management patients make changes in
accordance with a prior written action plan without needing to first contact their health care provider. With doctor-
directed self-management, patients still have a written action plan, but refer most major treatment decisions to their
physician at the time of a planned or unplanned consultation.
The essential components of effective guided asthma self-management education are:177
• Self-monitoring of symptoms and/or peak flow
• A written asthma action plan to show how to recognize and respond to worsening asthma; and
• Regular review of asthma control, treatment and skills by a health care provider.
Self-management education that includes these components dramatically reduces asthma morbidity, both in adults
(Evidence A)177,436,471 and children (Evidence A).178,471 Benefits include reduction of one-third to two-thirds in asthma-

3. Treating to control symptoms and minimize future risk 103

 related hospitalizations, emergency department visits and unscheduled doctor or clinic visits, missed work/school days,
and nocturnal wakening.177 It has been estimated that the implementation of a self-management program in 20 patients
prevents one hospitalization, and successful completion of such a program by 8 patients prevents one emergency
department visit.177,472 Less intensive interventions that involve self-management education but not a written action plan
are less effective,473 and information alone is ineffective.464 A systematic meta-review of 270 RCTs on supported self-
management for asthma confirmed that it reduces unscheduled healthcare use, improves asthma control, is applicable
to a wide range of target groups and clinical settings, and does not increase health care costs (Evidence A).471

Self-monitoring of symptoms and/or peak flow

Patients should be trained to keep track of their symptoms (with or without a diary), and notice and take action, if
necessary, when symptoms start to worsen. Peak expiratory flow (PEF) monitoring may sometimes be useful:
• Short-term monitoring
o Following an exacerbation, to monitor recovery
o Following a change in treatment, to help in assessing whether the patient has responded

TE
o If symptoms appear excessive (for objective evidence of degree of lung function impairment)

U
IB
o To assist in identification of occupational or domestic triggers for worsening asthma control

TR
• Long-term monitoring

IS
o For earlier detection of exacerbations, mainly in patients with poor perception of airflow limitation136

D
o For patients with a history of sudden severe exacerbations

R
O
o For patients who have difficult-to-control or severe asthma

PY
For patients carrying out PEF monitoring, use of a laterally compressed PEF chart (showing 2 months on a landscape
O
C
format page) allows more accurate identification of worsening asthma than other charts.158 One such chart is available
T

for download from www.woolcock.org.au/resources/asthma-peak-flow-chart.

O
N
O

There is increasing interest in internet or phone-based monitoring of asthma. Based on existing studies, the main benefit
-D

is likely to be for more severe asthma474 (Evidence B).

L
IA

Written asthma action plans

ER
AT

Personal written asthma action plans show patients how to make short-term changes to their treatment in response to
M

changes in their symptoms and/or PEF. They also describe how and when to access medical care.475,476 The term
D

‘written’ action plan includes printed, digital or pictorial plans, i.e., the patient is given a record of the instructions.
TE
H

The benefits of self-management education for asthma morbidity are greater in adults when the action plans include
IG

both a step up in ICS and the addition of OCS, and for PEF-based plans, when they are based on personal best rather
R
PY

than percent predicted PEF476 (Evidence A).

O
C

The efficacy of self-management education is similar regardless of whether patients self-adjust their medications
according to an individual written plan or whether the medication adjustments are made by a doctor (Evidence A).473
Thus, patients who are unable to undertake guided self-management can still achieve benefit from a structured program
of regular medical review.
Examples of written asthma action plan templates for asthma treatment with a SABA reliever, including for adult and
pediatric patients with low literacy, can be found on several websites (e.g. Asthma UK, www.asthma.org.uk; Asthma
Society of Canada, www.asthma.ca; Family Physician Airways Group of Canada, www.fpagc.com; National Asthma
Council Australia, www.nationalasthma.org.au) and in research publications.477,478
Action plan for patients using as-needed ICS-formoterol as their reliever
A different type of action plan is needed for patients using as-needed ICS-formoterol as their reliever in GINA Track 1,
because the initial ‘action’ when asthma worsens is for the patient to increase their as-needed doses of ICS-formoterol,
rather than taking a SABA and/or increasing their maintenance treatment. An example of such a customized template

104 3. Treating to control symptoms and minimize future risk

 can be found in a review article about practical use of maintenance-and reliever-therapy (MART).8 A similar action plan
template can be used for patients using as-needed-only ICS-formoterol.312
Health care providers should become familiar with action plans that are relevant to their local health care system,
treatment options, and cultural and literacy context. Details of the specific treatment adjustments that can be
recommended for written asthma action plans are described in the next chapter (Box 4-2, p.146).

Regular review by a healthcare provider or trained healthcare worker

The third component of effective asthma self-management education is regular review by a healthcare provider or
trained healthcare worker. Follow-up consultations should take place at regular intervals. Regular review should include
the following:
• Ask the patient if they have any questions or concerns.
Discuss issues, and provide additional educational messages as necessary; if available, refer the patient to
someone trained in asthma education.

TE
• Assess asthma control, risk factors for exacerbations, and comorbidities.

U
Review the patient’s level of symptom control and risk factors (Box 2-2, p.38).

IB
TR
Ask about flare-ups to identify contributory factors and whether the patient’s response was appropriate

IS
(e.g., was an action plan used?).

D
Review the patient’s symptom or PEF diary, if they keep one.

R
Assess comorbidities.

O
PY
• Assess treatment issues. O
Watch the patient use their inhaler, and correct and re-check technique if necessary (Box 3-22 p.100).
C

Assess medication adherence and ask about adherence barriers (Box 3-23, p.102).
T
O

Ask about adherence with other interventions (e.g., smoking cessation).

N
O

Review the asthma action plan and update it if level of asthma control or treatment have changed.479
-D

A single page prompt to clinicians has been shown to improve the provision of preventive care to children with asthma
L
IA

during office visits.480 Follow-up by telehealthcare is unlikely to benefit patients with asthma that is well controlled at a
ER

low treatment step, but may be of benefit in those with severe disease at risk of hospital admission.474
AT
M

School-based programs for children

D
TE

A systematic review found that school-based studies (most conducted in the US and Canada) that included self-
H

management skills for children aged 5–18 years was associated with a 30% decrease in emergency department visits,
IG

and a significant decrease in hospitalizations and in days of reduced activity.481

R
PY
O
C

3. Treating to control symptoms and minimize future risk 105

 3.4. MANAGING ASTHMA WITH MULTIMORBIDITY AND IN SPECIFIC POPULATIONS

KEY POINTS

• Multimorbidity is common in patients with chronic diseases such as asthma. It is important to identify and manage
multimorbidity, as it contributes to impaired quality of life, increased healthcare utilization, and adverse effects of
medications. In addition, comorbidities such as rhinosinusitis, obesity and gastro-esophageal reflux disease
(GERD) may contribute to respiratory symptoms and some contribute to poor asthma control.
• For patients with dyspnea or wheezing on exertion:
o Distinguish between exercise-induced bronchoconstriction (EIB) and symptoms that result from obesity or a lack of
fitness or are the result of alternative conditions such as inducible laryngeal obstruction.
o Provide advice about preventing and managing EIB.
• All adolescents and adults with asthma should receive ICS-containing treatment to reduce their risk of severe
exacerbations. It should be taken every day or, as an alternative in mild asthma, by as-needed ICS-formoterol for

TE
symptom relief.

U
IB
• Refer patients with difficult-to-treat or severe asthma to a specialist or severe asthma service, after addressing

TR
common problems such as incorrect diagnosis, incorrect inhaler technique, ongoing environmental exposures, and

IS
poor adherence (see Section 3.5, p.120).

D
R
O
MANAGING MULTIMORBIDITY PY
O
C

Multimorbidity is a common problem in patients with chronic diseases such as asthma. It is associated with worse quality
T
O

of life, increased healthcare utilization and increased adverse effects of treatment.175 Multimorbidity is particularly
N

common among those with difficult-to-treat or severe asthma.104 Active management of comorbidities such as
O
-D

rhinosinusitis, obesity and GERD is important, as these conditions may also contribute to respiratory symptom burden
L

and lead to medication interactions. Some comorbidities also contribute to poor asthma control.482
IA
ER

Obesity
AT
M

Clinical features
D
TE

Being overweight or obese is a risk factor for childhood asthma and wheeze, particularly in girls.483 Asthma is more
H

difficult to control in obese patients.395-398 This may be due to a different type of airway inflammation, contributory
IG

comorbidities such as obstructive sleep apnea and GERD, mechanical factors, or other as yet undefined factors. In
R
PY

addition, lack of fitness and reduction in lung volume due to abdominal fat may contribute to dyspnea.
O
C

Diagnosis
Document body-mass index (BMI) for all patients with asthma. Because of other potential contributors to dyspnea and
wheeze in obese patients, it is important to confirm the diagnosis of asthma with objective measurement of variable
expiratory airflow limitation (Box 1-2, p.25). Asthma is more common in obese than non-obese patients,62 but both over-
and under-diagnosis of asthma occur in obesity.38,63
Management
As for other patients with asthma, ICS are the mainstay of treatment in obese patients (Evidence B), although their
response may be reduced.398 Weight reduction should be included in the treatment plan for obese patients with asthma
(Evidence B). Increased exercise alone appears to be insufficient (Evidence B).404 Weight loss can improve asthma
control, lung function, health status and reduces medication needs in obese patients,400,401 but the studies have
generally been small, quality of some studies is poor, and the interventions and results have been variable.399 The most
striking results have been observed after bariatric surgery,402,403,484 but even 5–10% weight loss can lead to improved

106 3. Treating to control symptoms and minimize future risk

 asthma control and quality of life.404 For patients with comorbid obstructive sleep apnea, one study showed a significant
reduction in moderate exacerbations with 6 months of continuous positive airway pressure (CPAP) therapy.485

Gastroesophageal reflux disease (GERD)

Clinical features
GERD can cause symptoms such as heartburn and epigastric or chest pain, and is also a common cause of dry cough.
Symptoms and/or diagnosis of GERD are more common in people with asthma than in the general population,482 but
this may be in part due to cough being attributed to asthma; in addition, some asthma medications such as
beta2-agonists and theophylline cause relaxation of the lower esophageal sphincter. Asymptomatic gastroesophageal
reflux is not a likely cause of poorly controlled asthma.482
Diagnosis
In patients with confirmed asthma, GERD should be considered as a possible cause of a dry cough; however, there is
no value in screening patients with uncontrolled asthma for GERD (Evidence A). For patients with asthma and

TE
symptoms suggestive of reflux, an empirical trial of anti-reflux medication, such as a proton pump inhibitor or motility

U
IB
agent, may be considered, as in the general population. If the symptoms do not resolve, specific investigations such as

TR
24-hour pH monitoring or endoscopy may be considered.

IS
D
Management

R
O
Clinical trials of proton pump inhibitors in patients with confirmed asthma, most of whom had a diagnosis of GERD,

PY
showed small benefits for lung function, but no significant benefit for other asthma outcomes.486,487 In a study of adult
O
patients with symptomatic asthma but without symptoms of GERD, treatment with high-dose proton pump inhibitors did
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not reduce asthma symptoms or exacerbations.488 In general, benefits of proton pump inhibitors in asthma appear to be
O
N

limited to patients with both symptomatic reflux and night-time respiratory symptoms.489 Other treatment options include
O

motility agents, lifestyle changes and fundoplication. In summary, symptomatic reflux should be treated, but patients with
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poorly controlled asthma should not be treated with anti-reflux therapy unless they also have symptomatic reflux
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(Evidence A).487 Few data are available for children with asthma symptoms and symptoms of GERD.490,491
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AT

Anxiety and depression

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Clinical features
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Anxiety symptoms and psychiatric disorders, particularly depressive and anxiety disorders, are more prevalent among
H

people with asthma.492,493 Psychiatric comorbidity is also associated with worse asthma symptom control and medication
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adherence, and worse asthma-related quality of life.494 Anxious and depressive symptoms have been associated with
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increased asthma-related exacerbations and emergency visits.495 Panic attacks may be mistaken for asthma.
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Diagnosis
Although several tools are available for screening for anxious and depressive symptomatology in primary care, the
majority have not been validated in asthma populations. Difficulties in distinguishing anxiety or depression from asthma
symptoms may therefore lead to misdiagnosis. It is important to be alert to possible depression and/or anxiety in people
with asthma, particularly when there is a previous history of these conditions. Where appropriate, patients should be
referred to psychiatrists or evaluated with a disease-specific psychiatric diagnostic tool to identify potential cases of
depression and/or anxiety.
Management
There have been few good quality pharmacological and non-pharmacological treatment trials for anxiety or depression
in patients with asthma, and results are inconsistent. A Cochrane review of 15 randomized controlled trials of
psychological interventions for adults with asthma included cognitive behavior therapy, psychoeducation, relaxation, and
biofeedback.496 Results for anxiety were conflicting, and none of the studies found significant treatment differences for
depression. Drug treatments and cognitive behavior therapy497 have been described as having some potential in

3. Treating to control symptoms and minimize future risk 107

 patients with asthma; however, current evidence is limited, with a small number of studies and methodological
shortcomings.

Food allergy and anaphylaxis

Clinical features
Rarely, food allergy is a trigger for asthma symptoms (<2% of people with asthma). In patients with confirmed food-
induced allergic reactions (anaphylaxis), co-existing asthma is a strong risk factor for more severe and even fatal
reactions. Food-induced anaphylaxis often presents as life-threatening asthma.105 An analysis of 63 anaphylaxis-related
deaths in the United States noted that almost all had a past history of asthma; peanuts and tree nuts were the foods
most commonly responsible.498 A UK study of 48 anaphylaxis-related deaths found that most were regularly treated for
asthma, and that in most of these, asthma was poorly controlled.499
Diagnosis
In patients with confirmed food allergy, it is important to assess for asthma. Children with food allergy have a four-fold

TE
increased likelihood of having asthma compared with children without food allergy.500 Refer patients with suspected food

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allergy or intolerance for specialist allergy assessment. This may include appropriate allergy testing such as skin prick

TR
testing and/or blood testing for specific IgE. On occasion, carefully supervised food challenges may be needed.

IS
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Management

R
O
Patients who have a confirmed food allergy that puts them at risk for anaphylaxis must have an epinephrine auto-injector

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available at all times, and be trained how to use it. They, and their family, must be educated in appropriate food
O
avoidance strategies, and in the medical notes, they should be flagged as being at high risk. It is especially important to
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ensure that their asthma is well controlled, they have a written action plan, understand the difference between asthma
O
N

and anaphylaxis, and are reviewed on a regular basis.

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Rhinitis
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Clinical features
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Evidence clearly supports a link between diseases of the upper and lower airways.501 Most patients with asthma, either
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allergic or non-allergic, have concurrent rhinitis, and 10–40% of patients with allergic rhinitis have asthma.502 Depending
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on sensitization and exposure, allergic rhinitis may be seasonal (e.g. ragweed or grass pollen), or perennial (e.g., HDM
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allergens, furred pets in the home), or intermittent (e.g. furred pets at other locations).503 Rhinitis is defined as irritation
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and inflammation of the mucous membranes of the nose. Allergic rhinitis may be accompanied by ocular symptoms
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(conjunctivitis).
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Diagnosis
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Rhinitis can be classified as either allergic or non-allergic depending on whether allergic sensitization is demonstrated.
Variation in symptoms by season or with environmental exposure (e.g., furred pets, HDM, molds) suggests allergic
rhinitis. Examination of the upper airway should be arranged for patients with severe asthma.
Management
Evidence-based guidelines developed by Allergic Rhinitis in Asthma (ARIA)501 recommend intranasal corticosteroids for
treatment of allergic rhinitis. In a case-control study, treatment of rhinitis with intranasal corticosteroids was associated
with less need for asthma-related hospitalization and emergency department visits,504 but a meta-analysis found
improvement in asthma outcomes only in patients not also receiving ICS.505

Chronic rhinosinusitis with and without nasal polyps (CRSwNP and CRSsNP)
Rhinosinusitis is defined as inflammation of the nose and paranasal sinuses characterized by more than two symptoms
including nasal blockage/obstruction and/or nasal discharge (anterior/posterior nasal drip).506 Other symptoms may

108 3. Treating to control symptoms and minimize future risk

 include facial pain/pressure and/or a reduction or loss of smell. Sinusitis rarely occurs in the absence of rhinitis.
Rhinosinusitis is defined as acute when symptoms last <12 weeks with complete resolution, and chronic when
symptoms occur on most days for at least 12 weeks without complete resolution.
Chronic rhinosinusitis is an inflammatory condition of the paranasal sinuses that encompasses two clinically distinct
entities: chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP).507
The heterogeneity of chronic rhinosinusitis may explain the wide variation in prevalence rates in the general population
ranging from 1–10% without polyps and 4% with polyps. Chronic rhinosinusitis is associated with more severe asthma,
especially in patients with nasal polyps.508
Diagnosis
Nasendoscopy and/or computed tomography (CT) of the sinuses can identify changes suggestive of chronic
rhinosinusitis with or without nasal polyps. In severe asthma, presence of nasal polyps may help with choice of biologic
therapy (see Box 3-28, p.125).

TE
Management

U
Chronic rhinosinusitis, with or without nasal polyps, has a significant impact on patients’ quality of life. Guidelines about

IB
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the management of chronic rhinosinusitis with or without nasal polyps have been published.509,510 Few placebo-

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controlled studies have systematically evaluated the effect of proper treatment and management of chronic rhinosinusitis

D
on asthma control. A placebo-controlled trial of nasal mometasone in adults and children with chronic rhinosinusitis and

R
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poorly controlled asthma showed no benefit for asthma outcomes, suggesting that, while chronic rhinosinusitis can

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contribute to respiratory symptoms (e.g., chronic cough), its treatment in patients with asthma should be targeted at the
O
symptoms of rhinosinusitis rather than to improve asthma control.511
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Biologic therapy targeting T2 inflammation can significantly improve symptoms due to chronic rhinosinusitis with nasal
O
N

polyps. In patients with chronic rhinosinusitis with nasal polyps, omalizumab,512 mepolizumab513,514 and dupilumab515
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improved subjective and objective assessments including nasal symptoms and polyp size, compared with placebo.
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MANAGING ASTHMA DURING THE COVID-19 PANDEMIC

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Are people with asthma at higher risk of COVID-19 or severe COVID-19?

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People with asthma do not appear to be at increased risk of acquiring COVID-19, and systematic reviews have not
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shown an increased risk of severe COVID-19 in people with well-controlled mild to moderate asthma. Overall, studies to
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date indicate that people with well-controlled asthma are not at increased risk of COVID-19-related death,516,517 and in
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one meta-analysis, mortality appeared to be lower than in people without asthma.518 However, the risk of COVID-19
O

death was increased in people who had recently needed OCS for their asthma,516,519 and in hospitalized patients with
C

severe asthma.519,520 Therefore, it is important to continue good asthma management (as described in the GINA
Strategy Report), with strategies to maintain good symptom control, reduce the risk of severe exacerbations and
minimize the need for OCS. In one study of hospitalized patients aged ≥50 years with COVID-19, mortality was lower
among those with asthma who were using ICS than in patients without an underlying respiratory condition.520
In 2020 and 2021, many countries saw a reduction in asthma exacerbations and influenza-related illness. The reasons
are not precisely known, but may be due to handwashing, masks and social/physical distancing that reduced the
incidence of other respiratory infections, including influenza.521

During the pandemic, advise patients with asthma to continue taking their prescribed asthma medications,
particularly inhaled corticosteroid (ICS)-containing medications, and oral corticosteroids (OCS) if prescribed
It is important for patients to continue taking their prescribed asthma medications as usual during the COVID-19
pandemic. This includes ICS-containing medications (alone or in combination with a LABA, and add-on therapy
including biologic therapy for severe asthma. Stopping ICS often leads to potentially dangerous worsening of asthma.

3. Treating to control symptoms and minimize future risk 109

 See Chapter 3.2 (p.53) for information about asthma medications and regimens and non-pharmacologic strategies, and
Chapter 3.3 (p.98) for guided asthma self-management education and skills training.
For a small proportion of patients with severe asthma, long-term OCS may sometimes be needed, and it is very
dangerous to stop these suddenly. See Chapter 3.5 (p.120) for advice about investigation and management of difficult-
to-treat and severe asthma, including addition of biologic therapy for minimizing use of OCS.
Advise patients to discuss with you before stopping any asthma medication.

Make sure that all patients have a written asthma action plan
A written action plan (printed, digital or pictorial) tells the patient how to recognize worsening asthma, how to increase
their reliever and maintenance medications, and when to seek medical help. A short course of OCS may be needed
during severe asthma flare-ups (exacerbations). See Box 4-2 (p.146) for more information about specific action plan
options for increasing reliever medications (or reliever and maintenance medications), depending on the patient’s usual
therapeutic regimen.

TE
At present, there is no clear evidence about how to distinguish between worsening asthma due to respiratory viral

U
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infections such as rhinovirus and influenza, and COVID-19.

TR
IS
If local risk of COVID-19 is moderate or high, avoid use of nebulizers where possible due to the risk of

D
transmitting infection to other patients/family and to healthcare workers

R
O
Nebulizers can transmit respiratory viral particles across distances of at least 1 m. Use of nebulizers for delivering
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bronchodilator therapy is mainly restricted to management of life-threatening asthma in acute care settings. Instead, to
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deliver short-acting beta2-agonist for acute asthma in adults and children, use a pressurized metered-dose inhaler and
T

spacer, with a mouthpiece or tightly fitting face mask, if required. Check the manufacturer’s instructions about whether a
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N

spacer can be autoclaved. If not (as is the case for many types of spacers), or if in doubt, spacers should be restricted to
O

single patient use. If use of a nebulizer is needed in settings where COVID-19 infection is possible, strict infection control
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procedures should be followed.

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Remind patients not to share inhaler devices or spacers with family members, to avoid transmitting infection.
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Avoid spirometry in patients with confirmed/suspected COVID-19

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In healthcare facilities, follow local COVID-19 testing recommendations and infection control procedures if spirometry or
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peak flow measurement is needed.25 Use of an in-line filter minimizes the risk of transmission during spirometry, but
H
IG

many patients cough after performing spirometry; before performing spirometry, coach the patient to stay on the
R

mouthpiece if they feel the need to cough.

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The US Centers for Disease Control and Prevention (CDC) recommendations are found here. If spirometry is not
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available due to local infection control restrictions, and information about lung function is needed, consider asking
patients to monitor lung function at home.

Follow infection control recommendations if other aerosol-generating procedures are needed

Other aerosol-generating procedures include oxygen therapy (including with nasal prongs), sputum induction, manual
ventilation, non-invasive ventilation and intubation. CDC recommendations are found here. Follow local health advice
about hygiene strategies and use of personal protective equipment, as new information becomes available in your
country or region.
The CDC website provides up-to-date information about COVID-19 for health professionals here, and for patients here.
The website of the World Health Organization (WHO) provides comprehensive advice for health professionals and
health systems about prevention and management of COVID-19 here.

110 3. Treating to control symptoms and minimize future risk

Management of asthma if the patient acquires COVID-19
People with asthma who acquire COVID-19 are not at higher risk of severe COVID-19. However, be aware that those
with poorly controlled asthma (e.g. recent need for OCS) are at higher risk of hospitalization for severe disease if they
acquire COVID-19.516,519,520 Advise patients to continue taking their usual asthma medications. Patients with severe
asthma should continue biologic therapy or OCS, if prescribed.
To reduce the risk of transmitting infection, as above, avoid use of nebulizers where possible (use pMDI and spacer
instead), avoid spirometry, and instruct patients to avoid sharing of inhalers/spacers.
Before prescribing antiviral therapies, consult local prescribing guidelines. Check carefully for potential interactions
between asthma therapy and COVID-19 therapy. For example, ritonavir-boosted nirmatrelvir (NMV/r) is a potent
CYP3A4 inhibitor. While this is unlikely to cause clinically important corticosteroid-related adverse effects, because of
the short duration of anti-COVID-19 treatment, be cautious if considering prescribing NMV/r for patients taking ICS-
salmeterol or ICS-vilanterol, as the interaction may increase cardiac toxicity of the LABA.141 Product information
indicates that for patients taking ICS-salmeterol or ICS-vilanterol, concomitant treatment with CYP3A4 inhibitors is not

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recommended. Some drug interaction websites advise stopping ICS-salmeterol or ICS-vilanterol during NMV/r treatment

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and for a few days afterwards, but this may increase the risk of an asthma exacerbation. Instead, consider prescribing

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alternative antiviral therapy (if available) or switching to ICS alone or ICS-formoterol (if available) for the duration of

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NVM/r therapy and a further 5 days.141 If switching to a different inhaler, remember to teach correct technique with the

D
new inhaler.

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Advise people with asthma to be up to date with COVID-19 vaccines
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O
Many types of COVID-19 vaccines have been studied and are in use. New evidence about the vaccines, including in
C

people with asthma, will emerge over time. In general, allergic reactions to the vaccines are rare. Patients with a history
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of severe allergic reaction to a COVID-19 vaccine ingredient (e.g., polyethylene glycol for Pfizer/BioNTech or Moderna,
N

or polysorbate 80 for AstraZeneca or J&J/Janssen) should receive a different COVID-19 vaccine. However, people with
O
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anaphylaxis to foods, insect venom, or other medications can safely receive COVID-19 vaccines. More details from the
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US Advisory Committee on Immunization Practices (ACIP) are here. As always, patients should speak to their
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healthcare provider if they have concerns. Follow local advice about monitoring patients after COVID-19 vaccination.
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Usual vaccine precautions apply. For example, ask if the patient has a history of allergy to any components of the
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vaccine, and if the patient has a fever or another infection, delay vaccination until they are well.
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For people with severe asthma, GINA suggests that, if possible, the first dose of biologic therapy and COVID-19 vaccine
H

should not be given on the same day, to allow adverse effects of either to be more easily distinguished.
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Remind people with asthma to have an annual influenza vaccination (p.87). CDC (advice here) now advises that
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influenza vaccine and COVID-19 vaccine can be given on the same day.
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Current advice from the CDC is that where there is substantial transmission of COVID-19, people will be better
protected, even if they are fully vaccinated, if they wear a mask in indoor public settings. Further details are here.
Additional advice about management of asthma in the context of COVID-19 will be posted on the GINA website
(www.ginasthma.org) as it becomes available.

3. Treating to control symptoms and minimize future risk 111

MANAGING ASTHMA IN SPECIFIC POPULATIONS OR SETTINGS
This section includes brief advice about managing asthma in specific populations or settings in which the usual
treatment approach may need to be modified. Also refer to the Diagnosis of respiratory symptoms in other settings
section of Chapter 1 (p.30).

Low- and middle-income countries

Clinical features

In 2019, 96% of asthma deaths and 84% of disability-adjusted life years (DALYs) were in low- and middle-income
countries (LMICs).4 Symptoms of asthma are similar world-wide, but patient language may differ, and comorbidities may
vary depending on environmental exposures such as smoking and biomass fuel exposure and incidence of chronic
respiratory infections from tuberculosis and HIV/AIDS.

Management

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The fundamental principles and aims of asthma treatment are the same in LMICs as in high-income countries, but

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common barriers to effective long-term asthma care include the lack of availability and affordability of inhaled medicines,

TR
and prioritization of acute care over chronic care by healthcare systems.4,7

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R
Recommendations by WHO and the International Union Against Tuberculosis and Lung Disease (The Union)522 form the

O
basis of treatments offered in many LMICs.7 The WHO Model List of Essential Medicines523 includes ICS, combination
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ICS-formoterol, and bronchodilators. Spacers are included in the WHO list of essential technology but are rarely
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available due to obstacles to their manufacture or purchase, practical issues of cleaning, and inconvenience for
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ambulatory use. Effective spacers can be made at no cost from plastic drink bottles.524
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N
O

Medicines selected as ‘essential’ are not necessarily the most effective or convenient, particularly for patients with more
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severe disease, and a limited choice does not allow for consideration of patient preferences and likelihood of adherence.
L

However, ICS-containing medications, when provided for large populations, have achieved impressive reductions in
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mortality and morbidity,525 including in LMICs. In Brazil, government policy ensuring nationwide easy access to ICS, at
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no cost to patients, was associated with a 34% reduction in hospitalizations for asthma.168 Prescribing ICS-formoterol as
M

the symptom reliever, with (GINA Steps 3–5) or without (Steps 1–2) maintenance ICS-formoterol, provides the safest
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and most effective asthma treatment for adolescents and adults,167,213 and avoids the behavioral consequences of
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starting treatment with SABA alone.

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Inclusion of essential asthma medicines in formularies and guidelines does not assure sustained and equitable supply to
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patients. The supply of medicines in many LMICs tends to be sporadic for a wide variety of reasons, sometimes
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determined by the ability of governments to pay for supplies, issues relating to procurement, poor administration and
C

record keeping, and problems in the supply chain, particularly to remote dispensaries.5,7

Availability of asthma medicines varies widely between LMICs, with some having only oral bronchodilators (salbutamol
and theophylline tablets/solutions) supplemented from time to time with oral corticosteroids.9 Oral bronchodilators have
a slow onset of action and more adverse effects than inhaled SABA, and even occasional courses of OCS are
associated with a significant risk of short-term adverse effects such as pneumonia and sepsis,526 and, in adults, with
long-term adverse effects including osteoporosis and fragility fractures, cataract and diabetes.309 The largest
(52 countries) survey of the accessibility and affordability of inhaled asthma medicines, conducted in 2011, reported that
salbutamol was available in only half of public hospitals; ICS was available in fewer than one in five public pharmacies
and not at all in 14 countries.527

Obtaining asthma medicines often represents a catastrophic household expense. A recent systematic review of
published data on the availability, cost and affordability of essential medicines for asthma and COPD in LMICs found
these to be largely unavailable and unaffordable particularly for ICS and combination ICS-LABA.528 This means that the

112 3. Treating to control symptoms and minimize future risk

 essential cornerstone of treatment that achieves substantial reductions in morbidity and mortality is out of reach for the
great majority of the world’s children, adolescents and adults living with asthma.

It is not acceptable in 2023 for clinicians to have to manage asthma with SABAs and oral corticosteroids instead of
preventive ICS-containing treatments. The research community must develop and evaluate approaches designed to
obviate barriers to care in resource-constrained settings. A World Health Assembly Resolution on equitable access to
affordable care, including inhaled medicines, for children, adolescents and adults with asthma, wherever they live in the
world, would be a valuable step forward – as was recently achieved for the supply of insulin for diabetes.529 GINA
strongly supports this initiative.5

In the meantime, in general, Track 2 treatment, although less effective in reducing asthma exacerbations, may be
considered preferable in settings where current availability or affordability constrains the ability to implement Track 1
treatment. The “other controller options” in Box 3-12, though potentially less costly, may be considerably less effective
(e.g., LTRAs) or more harmful (e.g., maintenance OCS), or not well supported by evidence especially in the low-
resource setting (e.g., use of a low-dose ICS inhaler whenever a SABA is taken for symptom relief). Of these three other

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controller options, the third would be closest to the preferred recommendations in Tracks 1 and 2, as it would ensure

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that an ICS was provided, at least during symptomatic periods.9

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Adolescents

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Clinical features

O
PY
Care of teenagers with asthma should take into account the rapid physical, emotional, cognitive and social changes that
O
occur during adolescence. Asthma control may improve or worsen, although remission of asthma is seen more
C

commonly in males than females.530 Exploratory and risk-taking behaviors such as smoking occur at a higher rate in
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adolescents with chronic diseases than in healthy adolescents.

N
O

In a large meta-analysis of adherence with ICS by adolescents and young adults,174 overall adherence was 28%, and
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slightly higher in those <18 years (36%). However, pharmacy refill data provided lower estimates of adherence than self-
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report measures. Predictors of adherence included personality, illness perceptions, and treatment beliefs.
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Management
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M

General principles for managing chronic disease in adolescents have been published by WHO.531 Adolescents and their
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parent/caregivers should be encouraged in the transition towards asthma self-management by the adolescent.532 This
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may involve the transition from a pediatric to an adult health care facility. Transitioning should not be based on
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chronological age but on developmental stage and readiness, using formal tools to assess readiness at around 11–
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13 years (ideal timing/age not based on evidence). Clinicians should aim to increase self-management, focusing
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consultations on areas in which the young person is not confident. Consider using technology to assist with adherence
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and guide young people to web-based apps and tools to improve knowledge of asthma. Awareness of asthma should be
promoted to communities and peers.
During consultations, the adolescent should be seen separately from the parent/caregiver so that sensitive issues such
as smoking, adherence and mental health can be discussed privately, and confidentiality agreed. Information and self-
management strategies should be tailored to the patient’s stage of psychosocial development and desire for autonomy;
adolescents are often focused on short-term rather than long-term outcomes. An empathic approach should be used to
identify beliefs and behaviors that may be barriers to optimal treatment; for example, adolescents may be concerned
about the impact of treatment on their physical or sexual capabilities.
Medication regimens should be tailored to the adolescent’s needs and lifestyle, and reviews arranged regularly so that
the medication regimen can be adjusted for changing needs. Information about local youth-friendly resources and
support services should be provided, where available. In adolescents with mild asthma, use of as-needed low-dose
ICS-formoterol reduced risk of severe exacerbations compared with SABA alone, and without the need for daily
treatment. Change in height from baseline in younger adolescents was significantly greater with as-needed ICS-
formoterol than with daily low-dose ICS plus as-needed SABA.208

3. Treating to control symptoms and minimize future risk 113

Exercise-induced bronchoconstriction (EIB)
Clinical features
Physical activity is an important stimulus for asthma symptoms for many patients, with symptoms and
bronchoconstriction typically worsening after cessation of exercise. However, shortness of breath or wheezing during
exercise may also relate to obesity or a lack of fitness, or to comorbid or alternative conditions such as inducible
laryngeal obstruction.47,52
Management
Regular treatment with ICS significantly reduces EIB52 (Evidence A). Training and sufficient warm-up reduce the
incidence and severity of EIB52 (Evidence A). Taking SABAs, LABAs or chromones prior to exercise prevents EIB
(Evidence A), but tolerance to the protective effects of SABAs and LABAs against EIB develops with regular (more than
once-daily) use (Evidence A).52 However, in a 6-week study in patients with mild asthma, low-dose budesonide-
formoterol, taken as needed for relief of symptoms and before exercise, was non-inferior for reducing EIB to regular

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daily ICS with as-needed SABA.214 More studies are needed, but this suggests that patients with mild asthma who are

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prescribed as-needed low-dose ICS-formoterol to prevent exacerbations and control symptoms can use the same

IB
medication prior to exercise, if needed, and do not need to be prescribed a SABA for pre-exercise use (Evidence B).

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Chromone pMDIs have been discontinued globally.

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Breakthrough EIB often indicates poorly controlled asthma, and stepping up ICS-containing treatment (after checking

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inhaler technique and adherence) generally results in the reduction of exercise-related symptoms.

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Athletes
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Clinical features
O
N

Athletes, particularly those competing at a high level, have an increased prevalence of various respiratory conditions
O
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compared to non-athletes. They experience a higher prevalence of asthma, EIB, allergic or non-allergic rhinitis, chronic
cough, inducible laryngeal obstruction, and recurrent respiratory infections. Airway hyperresponsiveness is common in
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elite athletes, often without reported symptoms. Asthma in elite athletes is commonly characterized by less correlation
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between symptoms and pulmonary function; higher lung volumes and expiratory flows; less eosinophilic airway
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inflammation; more difficulty in controlling symptoms; and some improvement in airway dysfunction after cessation of
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training.
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Management
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Preventative measures to avoid high exposure to air pollutants, allergens (if sensitized) and chlorine levels in pools,
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particularly during training periods, should be discussed with the athlete. They should avoid training in extreme cold or
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pollution (Evidence C), and the effects of any therapeutic trials of asthma medications should be documented. Adequate
C

anti-inflammatory therapy, especially ICS, is advised; minimization of use of beta2-agonists will help to avoid the
development of tolerance.52 Information on treatment of exercise-induced asthma in athletes can be found in a Joint
Task Force Report prepared by the European Respiratory Society, the European Academy of Allergy and Clinical
Immunology, and Global Allergy and Asthma European Network (GA(2)LEN)533 and on the World Anti-Doping Agency
website (www.wada-ama.org).

Pregnancy
Clinical features
Asthma control often changes during pregnancy; in approximately one-third of women asthma symptoms worsen, in
one-third they improve, and in the remaining one-third they remain unchanged.534 Exacerbations are common in
pregnancy, particularly in the second trimester.106 Exacerbations and poor asthma control during pregnancy may be due
to mechanical or hormonal changes, or to cessation or reduction of asthma medications due to concerns by the mother

114 3. Treating to control symptoms and minimize future risk

 and/or the health care provider. Pregnant women appear to be particularly susceptible to the effects of viral respiratory
infections,535 including influenza.
Exacerbations and poor symptom control are associated with worse outcomes for both the baby (pre-term delivery, low
birth weight, increased perinatal mortality) and the mother (pre-eclampsia).106 Risk factors for asthma exacerbations
during pregnancy include severe asthma, multiparity, black ethnicity, depression and anxiety, current smoking, age
>35 years and obesity. Addressing these risk factors may not only reduce the risk of exacerbations, but also the risk of
adverse perinatal outcomes.536 If asthma is well controlled throughout pregnancy there is little or no increased risk of
adverse maternal or fetal complications.54
Management
Although there is a general concern about any medication use in pregnancy, the advantages of actively treating
asthma in pregnancy markedly outweigh any potential risks of usual asthma medications54 (Evidence A). For this
reason, using medications to achieve good symptom control and prevent exacerbations is justified even when their
safety in pregnancy has not been unequivocally proven. Use of ICS, beta2-agonists, montelukast or theophylline is not

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associated with an increased incidence of fetal abnormalities.537

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Importantly, ICS reduce the risk of exacerbations of asthma during pregnancy54,538,539 (Evidence A), and cessation of

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ICS during pregnancy is a significant risk factor for exacerbations106 (Evidence A). A study using administrative data

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reported that uncontrolled maternal asthma increased the risk of early-onset asthma in the offspring.540 One study

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reported that a treatment algorithm in non-smoking pregnant women based on monthly FeNO and ACQ was associated

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with significantly fewer exacerbations and better fetal outcomes than an algorithm based only on ACQ.541 However, the
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ACQ-only algorithm did not reflect current clinical recommendations, as LABA was introduced only after ICS had been
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increased to medium dose, and ICS could be stopped; 58% of women in the ACQ-only group were being treated without
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ICS by the end of pregnancy. In a follow-up study after 4-6 years, the prevalence of asthma was over 50% lower both in
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children of women in the FeNO group and in children of women receiving ICS in the ACQ group, compared with women
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in the clinical group who did not receive ICS.542 Use of ICS in early pregnancy (before randomization at weeks 12–20)
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also appeared to be protective for asthma in the child.542

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On balance, given the evidence in pregnancy and infancy for adverse outcomes from exacerbations during pregnancy
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(Evidence A),54 including due to lack of ICS or poor adherence,106 and evidence for safety of usual doses of ICS and
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LABA (Evidence A),537 a low priority should be placed on stepping down treatment (however guided) until after
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delivery (Evidence D), and ICS should not be stopped in preparation for pregnancy or during pregnancy
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(Evidence C).
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Despite lack of evidence for adverse effects of asthma treatment in pregnancy, many women and doctors remain
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concerned.543 Pregnant patients with asthma should be advised that poorly controlled asthma, and exacerbations,
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provide a much greater risk to their baby than do current asthma treatments. Educational resources about asthma
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management during pregnancy may provide additional reassurance.544 During pregnancy, monthly monitoring of asthma
is recommended.544 It is feasible for this to be achieved by pharmacist-clinician collaboration, with monthly telephone
monitoring of asthma symptom control.545 One observational study found that pregnant women whose asthma was well
controlled without controller therapy and who had no history of previous exacerbations were at low risk for exacerbations
during pregnancy.546 However, such women should still be closely monitored.
For women with severe asthma, evidence on use of biologic therapies during pregnancy is scarce.547 A registry study
found no evidence of an increased risk of major congenital malformations when mothers received omalizumab during
pregnancy. Women should be counselled that the potential risks associated with biologic exposure during pregnancy
need to be balanced against the risks for themselves and their children caused by uncontrolled asthma.548
Respiratory infections should be monitored and managed appropriately during pregnancy.535 During acute asthma
exacerbations, pregnant women may be less likely to be treated appropriately than non-pregnant patients.106 To avoid
fetal hypoxia, it is important to manage acute asthma exacerbations during pregnancy aggressively with SABA, oxygen,
and early administration of systemic corticosteroids.

3. Treating to control symptoms and minimize future risk 115

 During labor and delivery, usual maintenance medications should be taken, with reliever if needed. Acute exacerbations
during labor and delivery are uncommon, but bronchoconstriction may be induced by hyperventilation during labor, and
should be managed with SABA. Neonatal hypoglycemia may be seen, especially in preterm babies, when high doses of
beta-agonists have been given within the last 48 hours prior to delivery. If high doses of SABA have been given during
labor and delivery, blood glucose levels should be monitored in the baby (especially if preterm) for the first 24 hours.549
A review of asthma guidelines for the management of asthma during pregnancy highlighted the need for greater clarity
in current recommendations and the need for more RCTs among pregnant asthma patients.550

Women – perimenstrual asthma (catamenial asthma)

Clinical features
In approximately 20% of women, asthma is worse in the premenstrual phase. These women tend to be older, have more
severe asthma, a higher BMI, a longer duration of asthma, and a greater likelihood of aspirin-exacerbated respiratory
disease (AERD). They more often have dysmenorrhea, premenstrual syndrome, shorter menstrual cycles, and longer

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menstrual bleeding. The role of hormone levels and systemic inflammation remains unclear.551

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Management

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In addition to the usual strategies for management of asthma, oral contraceptives and/or leukotriene receptor

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antagonists may be helpful (Evidence D).551 Further research is needed.

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Occupational asthma
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Clinical features
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In the occupational setting, rhinitis often precedes the development of asthma (see p.30 regarding diagnosis of
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occupational asthma). Once a patient has become sensitized to an occupational allergen, the level of exposure
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necessary to induce symptoms may be extremely low; resulting exacerbations become increasingly severe, and with
continued exposure, persistent symptoms and irreversible airflow limitation may result.49
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Management
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Detailed information is available in evidence-based guidelines about management of occupational asthma.49 All patients
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with adult-onset asthma should be asked about their work history and other exposures (Evidence A). The early
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identification and elimination of occupational sensitizers and the removal of sensitized patients from any further
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exposure are important aspects of the management of occupational asthma (Evidence A). Attempts to reduce
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occupational exposure have been successful, especially in industrial settings.49 Cost-effective minimization of latex
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sensitization can be achieved by using non-powdered low-allergen gloves instead of powdered latex gloves.49 Patients
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with suspected or confirmed occupational asthma should be referred for expert assessment and advice, if this is
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available, because of the economic and legal implications of the diagnosis (Evidence A).

The elderly
Clinical features
Lung function generally decreases with longer duration of asthma and increasing age, due to stiffness of the chest wall,
reduced respiratory muscle function, loss of elastic recoil and airway wall remodeling. Older patients may not report
asthma symptoms, and may attribute breathlessness to normal aging or comorbidities such as cardiovascular disease
and obesity.552-554 Among the elderly, there is no increased risk of cardiovascular disease among those with asthma,
compared with those without asthma, except in current or former smokers.555 Comorbid arthritis may contribute to
reduced exercise capacity and lack of fitness, and make inhaler device use difficult. Asthma costs may be higher
amongst older patients, because of higher hospitalization rates and medication costs.553

116 3. Treating to control symptoms and minimize future risk

Management
Decisions about management of asthma in older people with asthma need to take into account both the usual goals of
symptom control and risk minimization and the impact of comorbidities, concurrent treatments and lack of self-
management skills.552,553 Data on efficacy of asthma medications in the elderly are limited because these patients are
often excluded from major clinical trials. Side-effects of beta2-agonists such as cardiotoxicity, and corticosteroid side-
effects such as skin bruising, osteoporosis and fragility fractures,556 and cataracts, are more common in the elderly than
in younger adults.552 Clearance of theophylline is also reduced.552 Elderly patients should be asked about all of the other
medications they are taking, including eye-drops, and potential drug interactions should be considered. Factors such as
arthritis, muscle weakness, impaired vision and inspiratory flow should be considered when choosing inhaler devices for
older patients,553,557 and inhaler technique should be checked at each visit. Older patients may have difficulties with
complex medication regimens, and prescribing of multiple inhaler devices should be avoided if possible. Large print
versions may be needed for written information such as asthma action plans. Patients with cognitive impairment may
require a carer to help them use their asthma medications. For diagnosis and initial management of patients with
asthma-COPD overlap, see Chapter 5, p.159.

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Aspirin-exacerbated respiratory disease (AERD)

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Clinical features

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The clinical picture and course of AERD (previously called aspirin-induced asthma) are well established.371 It starts with

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nasal congestion and anosmia, and progresses to chronic rhinosinusitis with nasal polyps that re-grow rapidly after

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surgery. Asthma and hypersensitivity to aspirin and NSAIDs develop subsequently. Following ingestion of aspirin or
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NSAIDs, an acute asthma attack develops within minutes to 1–2 hours. It is usually accompanied by rhinorrhea, nasal
C

obstruction, conjunctival irritation, and scarlet flush of the head and neck, and may sometimes progress to severe
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bronchospasm, shock, loss of consciousness, and respiratory arrest.558,559 AERD is more likely to be associated with low
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lung function and severe asthma,560,561 and with increased need for emergency care.561 The prevalence of AERD is 7%
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in general adult asthma populations, and 15% in severe asthma.561,562

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Diagnosis
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A history of exacerbation following ingestion of aspirin or other NSAIDs is highly suggestive of AERD. Aspirin challenge
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(oral, bronchial or nasal) is the gold standard for diagnosis563,564 as there are no reliable in vitro tests, but oral aspirin
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challenge tests must only be conducted in a specialized center with cardiopulmonary resuscitation capabilities because
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of the high risk of severe reactions.563,564 Bronchial (inhalational) and nasal challenges with lysine aspirin are safer than
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oral challenges and may be safely performed in allergy centers.564,565

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Management
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Patients with AERD should avoid aspirin or NSAID-containing products and other medications that inhibit
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cyclooxygenase-1 (COX-1), but this does not prevent progression of the disease. Where an NSAID is indicated for other
medical conditions, a COX-2 inhibitor (e.g. celecoxib or etoricoxib), or paracetamol (acetaminophen), may be
considered566,567 with appropriate health care provider supervision and observation for at least 2 hours after
administration568 (Evidence B). ICS are the mainstay of asthma therapy in AERD, but OCS are sometimes required;
LTRA may also be useful559,568 (Evidence B), but note the 2020 FDA warning about adverse effects with montelukast.236
See Chapter 3.5 (p.120) for treatment options for patients with severe asthma. An additional option is aspirin
desensitization, which may be conducted under specialist care in a clinic or hospital.569 Desensitization to aspirin
followed by daily aspirin treatment can significantly improve upper respiratory symptoms and overall quality of life,
decrease recurrence of nasal polyps, reduce the need for OCS and sinus surgery, and improve nasal and asthma
scores, but few double-blind studies have examined asthma outcomes.564,570,571 Aspirin desensitization is associated
with a significantly increased risk of adverse effects such as gastritis and gastrointestinal bleeding.571

3. Treating to control symptoms and minimize future risk 117

Allergic bronchopulmonary aspergillosis (ABPA)
Clinical features
Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disease characterized by repeated episodes of
wheezing, fleeting pulmonary opacities and development of bronchiectasis, sometimes with malaise, weight loss and
hemoptysis. Some patients expectorate brownish sputum plugs. ABPA is most commonly diagnosed in people with
asthma or cystic fibrosis, due to a hypersensitivity response to Aspergillus fumigatus, a common indoor and outdoor
mold.
Diagnosis
Diagnosis of ABPA is based on composite criteria including immediate hypersensitivity reaction to A. fumigatus, total
serum IgE, specific IgG to A. fumigatus, radiological features and blood eosinophils.572 Sensitization to fungal allergens,
without the full picture of ABPA, is often found in asthma, particularly in severe asthma, where it is sometimes called
‘severe asthma with fungal sensitization’.

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Management

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Current first-line therapy is with oral corticosteroids (e.g., a 4-month tapering course), with itraconazole reserved for

TR
those with exacerbations or requiring long-term OCS.573,574 575 Clinicians should be aware of the potential for drug

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interactions between itraconazole (a cytochrome P450 inhibitor) and asthma medications. These interactions may lead

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to increased risk of ICS adverse effects such as adrenal suppression and Cushing’s syndrome, and may increase the

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risk of cardiovascular adverse effects of some LABAs (salmeterol and vilanterol).141 Concomitant use is not
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recommended, so it may be appropriate to switch ICS-LABA treatment to an alternative product such as budesonide-
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formoterol or mometasone-formoterol for the duration of treatment with itraconazole.141
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A randomized double-blind placebo-controlled study in patients with severe asthma and ABPA found significantly fewer
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exacerbations with omalizumab (anti-IgE) than placebo.576 There have also been case series reports of treatment of
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ABPA with benralizumab, dupilumab and mepolizumab.

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In patients with ABPA and bronchiectasis, regular physiotherapy and daily drainage are recommended. Patients should
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be referred for specialist investigation and care if available.

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Difficult-to-treat and severe asthma are covered in the next section, Chapter 3.5.
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Surgery and asthma

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Clinical features
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There is no evidence of increased peri-operative risk for the general asthma population.577 However, there is an
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increased risk for patients with COPD,577 and this may also apply to asthma patients with reduced FEV1. The incidence
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of severe peri-operative bronchospasm in people with asthma is low, but it may be life threatening.578
Management
For elective surgery, meticulous attention should be paid pre-operatively to achieving good asthma control, as detailed
elsewhere in this chapter, especially for patients with more severe asthma, uncontrolled symptoms, exacerbation
history, or persistent airflow limitation (Evidence B).578 For patients requiring emergency surgery, the risks of proceeding
without first achieving good asthma control should be weighed against the need for immediate surgery. Patients taking
long-term high-dose ICS or who have received OCS for more than 2 weeks during the previous 6 months should receive
hydrocortisone peri-operatively as they are at risk of adrenal crisis in the context of surgery (Evidence B).579 More
immediate intra-operative issues relating to asthma management are reviewed in detail elsewhere.578 For all patients,
maintaining their prescribed ICS-containing therapy throughout the peri-operative period is important.

118 3. Treating to control symptoms and minimize future risk

Air travel and asthma
Practical advice for air travel by people with respiratory disease was published by the British Thoracic Society (BTS) in
2022.580 The advice for people with asthma included pre-flight optimization of treatment, carrying all asthma medications
and spacer (if used) in the cabin to allow immediate access during the flight (and in case checked luggage is mislaid),
and carrying a copy of the patient’s asthma action plan.

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3. Treating to control symptoms and minimize future risk 119

3.5. DIFFICULT-TO-TREAT AND SEVERE ASTHMA IN ADULTS AND ADOLESCENTS

KEY POINTS

What are difficult to treat and severe asthma?

• Difficult-to-treat asthma is asthma that is uncontrolled despite prescribing of medium or high-dose ICS-LABA
treatment or that requires high-dose ICS-LABA treatment to maintain good symptom control and reduce
exacerbations. It does not mean a ‘difficult patient’.
• Severe asthma is asthma that is uncontrolled despite adherence with optimized high-dose ICS-LABA therapy
and treatment of contributory factors, or that worsens when high-dose treatment is decreased. Approximately
3–10% of people with asthma have severe asthma.
• Severe asthma places a large physical, mental, emotional, social and economic burden on patients. It is often
associated with multimorbidity.

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How should these patients be assessed?

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• Assess all patients with difficult-to-treat asthma to confirm the diagnosis of asthma, and to identify and manage

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factors that may be contributing to symptoms, poor quality of life, or exacerbations.

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• Refer for expert advice at any stage, or if asthma does not improve in response to optimizing treatment.

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• For patients with persistent symptoms and/or exacerbations despite high-dose ICS, the clinical or inflammatory

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phenotype should be assessed, as this may guide the selection of add-on treatment.
Management of severe asthma PY
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• Depending on the inflammatory phenotype and other clinical features, add-on treatments for severe asthma
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include LAMA, LTRA, low-dose azithromycin (adults), and biologic agents for severe asthma.
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• Low-dose maintenance OCS should be considered only as a last resort if no other options are available,
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because of their serious long-term side-effects.

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• Assess the response to any add-on treatment, stop ineffective treatments, and consider other options.
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• Utilize specialist multidisciplinary team care for severe asthma, if available.

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• For patients with severe asthma, continue to optimize patient care in collaboration with the primary care
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clinician, and taking into account the patient’s social and emotional needs.
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• Invite patients with severe asthma to enroll in a registry or clinical trial, if available and relevant, to help fill
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evidence gaps.
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See Boxes 3-26 to 3-29 (starting on p.123) for the GINA severe asthma decision tree.
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Although the majority of patients can achieve the goal of well controlled asthma, some patients’ asthma will not be well
controlled even with optimal therapy. This section is also published separately as a GINA short guide for health
professionals: Difficult-to-Treat and Severe Asthma in Adolescent and Adult Patients. Diagnosis and Management. V4.0,
2023 (the Severe Asthma Guide), available to download or order from the GINA website (www.ginasthma.org).
Other resources about severe asthma include an online toolkit published by the Australian Centre of Excellence in
Severe Asthma (www.toolkit.severeasthma.org.au).

120 3. Treating to control symptoms and minimize future risk

DEFINITIONS: UNCONTROLLED, DIFFICULT-TO-TREAT AND SEVERE ASTHMA
Understanding the definitions of difficult-to-treat and severe asthma starts with the concept of uncontrolled asthma.
Uncontrolled asthma includes one or both of the following:
• Poor symptom control (frequent symptoms or reliever use, activity limited by asthma, night waking due to
asthma)
• Frequent exacerbations (≥2/year) requiring OCS, or serious exacerbations (≥1/year) requiring hospitalization.
Difficult-to-treat asthma159 is asthma that is uncontrolled despite prescribing of medium- or high-dose ICS with a
second controller (usually a LABA) or with maintenance OCS, or that requires high-dose treatment to maintain good
symptom control and reduce the risk of exacerbations.159 It does not mean a ‘difficult patient’. In many cases, asthma
may appear to be difficult to treat because of modifiable factors such as incorrect inhaler technique, poor adherence,
smoking or comorbidities, or because the diagnosis is incorrect.
Severe asthma159 is a subset of difficult-to-treat asthma (Box 3-15). It means asthma that is uncontrolled despite

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adherence with maximal optimized high-dose ICS-LABA treatment and management of contributory factors, or that

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worsens when high-dose treatment is decreased.159 At present, therefore, ‘severe asthma’ is a retrospective label. It is

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sometimes called ‘severe refractory asthma’159 since it is defined by being relatively refractory to high-dose inhaled

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therapy. However, with the advent of biologic therapies, the word ‘refractory’ is no longer appropriate.

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Asthma is not classified as severe if it markedly improves when contributory factors such as inhaler technique and

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adherence are addressed.159

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PREVALENCE: HOW MANY PEOPLE HAVE SEVERE ASTHMA?
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A study in the Netherlands estimated that around 3.7% of asthma patients have severe asthma, based on the number of
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patients prescribed high-dose ICS-LABA, or medium or high-dose ICS-LABA plus long-term OCS, who had poor
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symptom control (by Asthma Control Questionnaire) and had good adherence and inhaler technique (Box 3-15).581
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Box 3-25. What proportion of adults have difficult-to-treat or severe asthma?

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See list of abbreviations (p.10). Data from the Netherlands, reported by Hekking et al (2015)581

3. Treating to control symptoms and minimize future risk 121

IMPORTANCE: THE IMPACT OF SEVERE ASTHMA

The patient perspective

Patients with severe asthma experience a heavy burden of symptoms, exacerbations and medication side-effects.
Frequent shortness of breath, wheeze, chest tightness and cough interfere with day-to-day living, sleeping, and physical
activity, and patients often have frightening or unpredictable exacerbations (also called attacks or severe flare-ups).
Medication side-effects are particularly common and problematic with OCS,308 which in the past were a mainstay of
treatment for severe asthma. Adverse effects of long-term or frequent OCS include obesity, diabetes, osteoporosis and
fragility fractures,556 cataracts, hypertension and adrenal suppression; psychological side-effects such as depression
and anxiety are particularly concerning for patients.582 Even short-term use of OCS is associated with sleep disturbance,
and increased risk of infection, fracture and thromboembolism.526 Strategies to minimize need for OCS are therefore a
high priority.
Severe asthma often interferes with family, social and working life, limits career choices and vacation options, and

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affects emotional and mental health. Patients with severe asthma often feel alone and misunderstood, as their

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experience is so different from that of most people with asthma.582

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Adolescents with severe asthma

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The teenage years are a time of great psychological and physiological development which can impact on asthma

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management. It is vital to ensure that the young person has a good understanding of their condition and treatment and

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appropriate knowledge to enable supported self-management. The process of transition from pediatric to adult care
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should help support the young person in gaining greater autonomy and responsibility for their own health and wellbeing.
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Severe asthma may improve over 3 years in approximately 30% of male and female adolescents; the only predictor of
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asthma becoming non-severe was higher baseline blood eosinophils.583 Studies with longer follow-up time are needed.
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Healthcare utilization and costs

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Severe asthma has very high healthcare costs due to medications, physician visits, hospitalizations, and the costs of
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OCS side-effects. In a UK study, healthcare costs per patient were higher than for type 2 diabetes, stroke, or COPD.584
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In a Canadian study, severe uncontrolled asthma was estimated to account for more than 60% of asthma costs.585
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Patients with severe asthma and their families also bear a significant financial burden, not only for medical care and
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medications, but also through lost earnings and career choices.

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ASSESSMENT AND MANAGEMENT OF DIFFICULT-TO-TREAT AND SEVERE ASTHMA

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The clinical decision tree starting on page 123, provides brief information about what should be considered in each
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phase of diagnosis and management of difficult-to-treat and severe asthma. The decision tree is divided into three broad
areas:
• Sections 1–4 (green) are for use in primary care and/or specialist care.
• Sections 5–8 (blue) are mainly relevant to respiratory specialists.
• Sections 9–10 (brown) are about maintaining ongoing collaborative care between the patient, primary care
physician, specialist and other health professionals.
Development of the Severe Asthma Guide and decision tree included extensive collaboration with experts in human-
centered design to enhance the utility of these resources for end-users. This included translating existing high-level
flowcharts and text-based information to a more detailed visual format, and applying information architecture and
diagramming principles.
The decision tree is followed by more detailed information on each stage of assessment and management.

122 3. Treating to control symptoms and minimize future risk

 Box 3-26. Decision tree – investigate and manage difficult to treat asthma in adult and adolescent patients

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See list of abbreviations (p.10).

3. Treating to control symptoms and minimize future risk 123

Box 3-27. Decision tree – assess and treat severe asthma phenotypes

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See list of abbreviations (p.10).

124 3. Treating to control symptoms and minimize future risk

 Box 3-28. Decision tree – consider add-on biologic Type 2-targeted treatments

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See list of abbreviations (p.10).

3. Treating to control symptoms and minimize future risk 125

Box 3-29. Decision tree – monitor and manage severe asthma treatment

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See list of abbreviations (p.10).

126 3. Treating to control symptoms and minimize future risk

INVESTIGATE AND MANAGE DIFFICULT-TO-TREAT ASTHMA IN ADULTS AND ADOLESCENTS

1. CONFIRM THE DIAGNOSIS (ASTHMA OR DIFFERENTIAL DIAGNOSES)

Stages 1–5 can be carried out in primary or specialist care. A patient is classified as having difficult-to-treat asthma if
they patient have persistent asthma symptoms and/or exacerbations despite prescribing of medium or high-dose ICS
with another controller such as LABA, or maintenance OCS, or require high-dose ICS-LABA treatment to maintain good
symptom control and prevent exacerbations. Difficult-to-treat asthma does not mean a ‘difficult patient’.
Consider referral to a specialist or severe asthma clinic at any stage, particularly if:
• There is difficulty confirming the diagnosis of asthma
• Patient has frequent urgent healthcare utilization
• Patient needs frequent or maintenance OCS

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• Occupational asthma is suspected

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• Food allergy or anaphylaxis, as this increases the risk of death

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• Symptoms are suggestive of infective or cardiac cause

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• Symptoms are suggestive of complications such as bronchiectasis

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• Patient has multimorbidity.

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Are the symptoms due to asthma? O
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Perform a careful history and physical examination to identify whether symptoms are typical of asthma, or are more
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likely due to an alternative diagnosis or comorbidity:

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• Dyspnea: COPD, obesity, cardiac disease, deconditioning

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• Cough: inducible laryngeal obstruction (also called vocal cord dysfunction, VCD), upper airway cough syndrome
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(also called post-nasal drip), gastro-esophageal reflux disease (GERD), bronchiectasis, ACE inhibitors
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• Wheeze: obesity, COPD, tracheobronchomalacia, VCD.

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Investigate according to clinical suspicion and age (see Box 1-5, p.30).
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How can the diagnosis of asthma be confirmed?

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Confirmation of the diagnosis is important, because in 12–50% of people assumed to have severe asthma, asthma is
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not found to be the correct diagnosis.586 Perform spirometry, before and after bronchodilator, to assess baseline lung
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function and seek objective evidence of variable expiratory airflow limitation. If initial bronchodilator responsiveness
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testing is negative (≤200 mL or ≤12% increase in FEV1), consider repeating after withholding bronchodilators or when
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symptomatic, or consider stepping controller treatment up or down before further investigations such as bronchial
provocation testing (see Box 1-3, p.28). Check full flow-volume curve to assess for upper airway obstruction. If
spirometry is normal or is not available, provide the patient with a peak flow meter and diary for assessing variability;
consider bronchial provocation testing if patient is able to withhold bronchodilators (SABA for at least 6 hours, LABA for
up to 2 days depending on duration of action).32 Strategies for confirming the diagnosis of asthma in patients already
taking ICS-containing treatment are shown in Box 1-3 (p.28).
Airflow limitation may be persistent in patients with long-standing asthma, due to remodeling of the airway walls, or
limited lung development in childhood. It is important to document lung function when the diagnosis of asthma is first
made. Specialist advice should be obtained if the history is suggestive of asthma but the diagnosis cannot be confirmed
by spirometry.

3. Treating to control symptoms and minimize future risk 127

2. LOOK FOR FACTORS CONTRIBUTING TO SYMPTOMS AND EXACERBATIONS
Systematically consider factors that may be contributing to uncontrolled symptoms or exacerbations, or poor quality of
life, and that can be treated. The most important modifiable factors include:
• Incorrect inhaler technique (seen in up to 80% patients): ask the patient to show you how they use their
inhaler; compare with a checklist or video.
• Suboptimal adherence (up to 75% asthma patients): ask empathically about frequency of use (e.g., ‘Many
patients don’t use their inhaler as prescribed. In the last 4 weeks, how many days a week have you been taking
it – not at all, 1 day a week, 2, 3 or more?’ or, ‘Do you find it easier to remember your inhaler in the morning or
the evening?’ (see Box 3-23, p.102). Ask about barriers to medication use, including cost, and concerns about
necessity or side-effects. Check dates on inhalers and view dispensing data, if available. Electronic inhaler
monitoring, if available, can be helpful in screening for poor adherence.
• Comorbidities: review history and examination for comorbidities that can contribute to respiratory symptoms,
exacerbations, or poor quality of life. These include anxiety and depression, obesity, deconditioning, chronic

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rhinosinusitis, inducible laryngeal obstruction, GERD, COPD, obstructive sleep apnea, bronchiectasis, cardiac

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disease, and kyphosis due to osteoporosis. Investigate according to clinical suspicion.

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• Modifiable risk factors and triggers: identify factors that increase the risk of exacerbations, e.g., smoking,

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environmental tobacco exposure, other environmental exposures at home or work including allergens (if

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sensitized), indoor and outdoor air pollution, molds and noxious chemicals, and medications such as beta-

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blockers or non-steroidal anti-inflammatory drugs (NSAIDs). For allergens, check for sensitization using skin

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prick testing or specific IgE. O
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• Regular or over-use of SABAs: regular SABA use causes beta-receptor down-regulation and reduction in
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response,587 leading in turn to greater use. Over-use may also be habitual. Dispensing of ≥3 SABA canisters per
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year (corresponding to average use more than daily) is associated with increased risk of emergency department
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visit or hospitalization independent of severity,74,75 and dispensing of ≥12 canisters per year (one a month) is
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associated with substantially increased risk of death.75,100 Risks are higher with nebulized SABA.588
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• Anxiety, depression and social and economic problems: these are very common in asthma, particularly in
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difficult asthma582 and contribute to symptoms, impaired quality of life, and poor adherence.
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• Medication side-effects: systemic effects, particularly with frequent or continuous OCS, or long-term high-dose
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ICS may contribute to poor quality of life and increase the likelihood of poor adherence. Local side-effects of
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dysphonia or thrush may occur with high-dose or potent ICS, especially if inhaler technique is poor. Consider
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drug interactions including risk of adrenal suppression with use of P450 inhibitors such as itraconazole.
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3. REVIEW AND OPTIMIZE MANAGEMENT

O
C

Review and optimize treatment for asthma, and for comorbidities and risk factors identified in Section 2. For more
details, see Chapter 3.4, p.106.
• Provide asthma self-management education, and confirm that patient has (and knows how to use) a
personalized written or electronic asthma action plan. Refer to an asthma educator if available.
• Optimize asthma medications: confirm that the inhaler is suitable for the patient; check and correct inhaler
technique with a physical demonstration and teach-back method, check inhaler technique again at each visit.589
Address suboptimal adherence, both intentional and unintentional.458 Switch to ICS-formoterol maintenance and
reliever regimen if available, to reduce the risk of exacerbations.213
• Consider non-pharmacologic add-on therapy, e.g., smoking cessation, physical exercise,367 healthy diet,
weight loss, mucus clearance strategies, influenza vaccination, breathing exercises, allergen avoidance, if
feasible, for patients who are sensitized and exposed. For details see text following Box 3-18, p.88.

128 3. Treating to control symptoms and minimize future risk

 • Treat comorbidities and modifiable risk factors identified in Section 2 of the decision tree, where there is
evidence for benefit; however, there is no evidence to support routine treatment of asymptomatic GERD (see
p.107). Avoid medications that make asthma worse (beta-blockers including eye-drops; aspirin and other
NSAIDs in patients with aspirin-exacerbated respiratory disease, p.117). Refer for management of mental health
problems if relevant.
• Consider trial of non-biologic medication added to medium/high dose ICS, e.g., LABA, LAMA, LTRA if not
already tried. Note FDA boxed warning about potential neuropsychiatric effects with LTRAs.236
• Consider trial of high-dose ICS-LABA if not currently used.

4. REVIEW RESPONSE AFTER APPROXIMATELY 3–6 MONTHS

Schedule a review visit to assess the response to the above interventions. Timing of the review visit depends on clinical
urgency and what changes to treatment have been made.
When assessing the response to treatment, specifically review:

TE
• Symptom control (symptom frequency, SABA reliever use, night waking due to asthma, activity limitation)

U
IB
• Exacerbations since previous visit, and how they were managed

TR
IS
• Medication side-effects

D
• Inhaler technique and adherence

R
O
• Lung function
PY
• Patient satisfaction and concerns.
O
C
T

Is asthma still uncontrolled, despite optimized therapy?

O
N

YES: if asthma is still uncontrolled, the diagnosis of severe asthma has been confirmed. If not done by now, refer the
O
-D

patient to a specialist or severe asthma clinic if possible.

L

NO: if asthma is now well controlled, consider stepping down treatment. Start by decreasing/ceasing OCS first (if used),
IA
ER

checking for adrenal insufficiency, then remove other add-on therapy, then decrease ICS dose, but do not stop ICS. See
Box 3-16 (p.83) for how to gradually down-titrate treatment intensity.
AT
M

Does asthma become uncontrolled when treatment is stepped down?

D
TE

YES: if asthma symptoms become uncontrolled or an exacerbation occurs when high-dose treatment is stepped down,
H

the diagnosis of severe asthma has been confirmed. Restore the patient's previous dose to regain good asthma control,
IG
R

and refer to a specialist or severe asthma clinic if possible, if not done already.
PY

NO: if symptoms and exacerbations remain well controlled despite treatment being stepped down, the patient does not
O
C

have severe asthma. Continue optimizing management.

ASSESS AND TREAT SEVERE ASTHMA PHENOTYPES

5. INVESTIGATE FURTHER AND PROVIDE PATIENT SUPPORT

Further assessment and management should be by a specialist, preferably in a multidisciplinary severe asthma clinic if
available. The team may include a certified asthma educator and health professionals from fields such as speech
pathology, otorhinolaryngology, social work and mental health.
What other tests may be considered at the specialist level?
Additional investigations may be appropriate for identifying less-common comorbidities and differential diagnoses
contributing to symptoms and/or exacerbations. Tests should be based on clinical suspicion, and may include:
• Blood tests: complete blood count, CRP, IgG, IgA, IgM, IgE, fungal precipitins including Aspergillus

3. Treating to control symptoms and minimize future risk 129

 • Allergy testing for clinically relevant allergens: skin prick test or specific IgE, if not already done
• Other pulmonary investigations: DLCO; CXR or high-resolution chest CT
• Bone density scan, because of risk of osteoporosis with maintenance or frequent OCS or long-term high-dose
ICS311
• Other directed testing, e.g., ANCA, CT sinuses, BNP, echocardiogram, based on clinical suspicion
If blood eosinophils are ≥300/µL, look for and treat non-asthma causes, including parasites (e.g., Strongyloides serology
or stool examination), because parasitic infection may be the cause of the blood eosinophilia, and because OCS or
biologic therapy in a patient with untreated parasitic infection could potentially lead to disseminated disease.
Strongyloides infection is usually asymptomatic.590
If hypereosinophilia is found, e.g., blood eosinophils ≥1500/µL, consider causes such as eosinophilic granulomatosis
with polyangiitis (EGPA).
Consider need for social/psychological support

TE
Refer patients to support services, where available, to help them deal with the emotional, social and financial burden of

U
IB
asthma and its treatment, including during and after severe exacerbations.582 Consider the need for psychological or

TR
psychiatric referral, including for patients with anxiety and/or depression.

IS
D
Involve multidisciplinary team care (if available)

R
O
Multidisciplinary assessment and treatment of patients with severe asthma increases the identification of comorbidities,

PY
and improves outcomes.591 O
C
Invite patient to enroll in a registry (if available) or clinical trial (if appropriate)
T
O

Systematic collection of data will help in understanding the mechanisms and burden of severe asthma. There is a need
N
O

for pragmatic clinical trials in severe asthma, including studies comparing two or more active treatments. Participants in
-D

randomized controlled trials designed for regulatory purposes may not necessarily be representative of patients seen in
L

clinical practice. For example, a registry study found that over 80% of patients with severe asthma would have been
IA
ER

excluded from key studies evaluating biologic therapy.288

AT

6 ASSESS THE SEVERE ASTHMA PHENOTYPE

M
D

The next step is to assess the patient’s inflammatory phenotype – is it Type 2 high or low?
TE
H

What is Type 2 inflammation?

IG
R

Type 2 inflammation is found in the majority of people with severe asthma. It is characterized by cytokines such as
PY

interleukin (IL)-4, IL-5 and IL-13, which are often produced by the adaptive immune system on recognition of allergens. It
O
C

may also be activated by viruses, bacteria and irritants that stimulate the innate immune system via production of IL-33,
IL-25 and thymic stromal lymphopoietin (TSLP) by epithelial cells. Type 2 inflammation is often characterized by
elevated eosinophils or increased FeNO, and it may be accompanied by atopy and elevated IgE, whereas non-Type 2
inflammation is often characterized by increased neutrophils.592
In many patients with asthma, Type 2 inflammation rapidly improves when ICS are taken regularly and correctly; this is
classified as mild or moderate asthma. In severe asthma, Type 2 inflammation may be relatively refractory to high-dose
ICS. It may respond to OCS but their serious adverse effects308,309 mean that alternative treatments should be sought.
In adult patients with uncontrolled asthma despite medium- or high-dose ICS plus LABA or other controllers, a history of
exacerbations in the previous year, higher blood eosinophil counts and higher FeNO levels are associated with a greater
risk of severe exacerbations.593

130 3. Treating to control symptoms and minimize future risk

Could the patient have refractory or underlying Type 2 inflammation?
The possibility of refractory Type 2 inflammation should be considered if any of the following are found while the patient
is taking high-dose ICS or daily OCS:
• Blood eosinophils ≥150/μl, and/or
• FeNO ≥20 ppb, and/or
• Sputum eosinophils ≥2%, and/or
• Asthma is clinically allergen-driven
Patients requiring maintenance OCS may also have underlying Type 2 inflammation. However, biomarkers of Type 2
inflammation (blood eosinophils, sputum eosinophils and FeNO) are often suppressed by OCS. If possible, therefore,
these tests should be performed before starting OCS (a short course, or maintenance treatment), or at least 1–2 weeks
after a course of OCS, or on the lowest possible OCS dose.
The above criteria are suggested for initial assessment; those for blood eosinophils and FeNO are based on the lowest

TE
levels associated with response to some biologics. They are not the criteria for eligibility for Type 2-targeted biologic

U
therapy, which may differ – see section 8 and local criteria.

IB
TR
Consider repeating blood eosinophils and FeNO up to 3 times (e.g., when asthma worsens, before giving OCS, or at

IS
least 1–2 weeks after a course of OCS, or on the lowest possible OCS dose), before assuming asthma is non-Type 2.

D
R
One study of patients with uncontrolled asthma taking medium- to high-dose ICS-LABA found that 65% had a shift in

O
their blood eosinophil category over 48–56 weeks.594
PY
O
Why is the inflammatory phenotype assessed on high-dose ICS?
C

• Most RCT evidence about Type 2 targeted biologics is in such patients.

T
O
N

• Modifiable ICS treatment problems such as poor adherence and incorrect inhaler technique are common causes of
O

uncontrolled Type 2 inflammation

-D

• Currently, the high cost of biologic therapies generally precludes their widespread clinical use in patients whose
L
IA

symptoms or exacerbations and Type 2 biomarkers are found to respond to ICS when it is taken correctly.
ER
AT

7.1. CONSIDER OTHER TREATMENTS IF THERE IS NO EVIDENCE OF TYPE 2 INFLAMMATION

M

If the patient has no evidence of persistent Type 2 inflammation (section 6):

D
TE

• Review the basics for factors that may be contributing to symptoms or exacerbations: differential diagnosis, inhaler
H

technique, adherence, comorbidities, medication side-effects (Section 2).

IG
R

• Recommend avoidance of relevant exposures (tobacco smoke, pollution, allergens if sensitized and there is
PY

evidence of benefit from withdrawal, irritants, infections). Ask about exposures at home and at work.
O
C

• Consider additional diagnostic investigations (if available and not already done): sputum induction to confirm
inflammatory phenotype, high resolution chest CT, bronchoscopy to exclude unusual comorbidities or alternative
diagnoses such as tracheobronchomalacia or sub-glottic stenosis; functional laryngoscopy for inducible laryngeal
obstruction.
• Consider a trial of add-on treatment if available and not already tried (but check local eligibility and payer criteria for
specific therapies as they may vary from those listed):
– LAMA272
– Low-dose azithromycin (adults),292,595 but first check sputum for atypical mycobacteria, check ECG for long QTc
(and re-check after a month on treatment), and consider potential for antibiotic resistance.
– Anti-IL4Rα if taking maintenance OCS (see section 8 for more details)
– Anti-TSLP (thymic stromal lymphopoietin) (but insufficient evidence in patients taking maintenance OCS; see
section 8 for more details)

3. Treating to control symptoms and minimize future risk 131

 As a last resort, consider add-on low-dose OCS, but implement strategies such as alternate-day treatment to
minimize side-effects.
• Consider bronchial thermoplasty, with registry enrollment. However, the evidence for efficacy and long-term safety
is limited.134,354
• Stop ineffective add-on therapies.
• Continue to optimize treatment, including inhaler technique, adherence, non-pharmacologic strategies and treating
comorbidities (see sections 3 and 10).

7.2 CONSIDER NON-BIOLOGIC OPTIONS IF THERE IS EVIDENCE OF TYPE 2 INFLAMMATION

For patients with elevated Type 2 biomarkers despite high-dose ICS (see section 5), consider non-biologic options first,
given the current high cost of biologic therapy:
• Assess adherence objectively by monitoring of prescribing or dispensing records, blood prednisone levels,596 or
electronic inhaler monitoring.444 In one study, suppression of high FeNO after 5 days of directly observed therapy

TE
was an indicator of past poor adherence.597

U
IB
• Consider increasing the ICS dose for 3–6 months, and review again.

TR
• Consider add-on non-biologic treatment for specific Type 2 clinical phenotypes (see Chapter 3.4, p.106). For

IS
example, for aspirin-exacerbated respiratory disease (AERD), consider add-on LTRA and possibly aspirin

D
R
desensitization (p.117). For allergic bronchopulmonary aspergillosis (ABPA), consider add-on OCS ± anti-fungal

O
agent (p.118). For chronic rhinosinusitis with or without nasal polyps, consider intensive intranasal corticosteroids;
PY
surgical advice may be needed (p.108). For patients with atopic dermatitis, topical steroidal or non-steroidal
O
C
therapy may be helpful.
T
O
N

7.3 IS TYPE 2-TARGETED BIOLOGIC THERAPY AVAILABLE AND AFFORDABLE?

O
-D

If NOT:
L

• Consider higher dose ICS-LABA, if not used

IA
ER

• Consider other add-on therapy, e.g., LAMA, LTRA, low-dose azithromycin if not used
AT

• As last resort, consider add-on low-dose OCS, but implement strategies to minimize side-effects
M
D

• Stop ineffective add-on therapies

TE

• Continue to optimize treatment, including inhaler technique, adherence, non-pharmacologic strategies and treating
H
IG

comorbidities (see sections 3 and 10).

R
PY

8 CONSIDER ADD-ON BIOLOGIC TYPE 2-TARGETED TREATMENTS

O
C

If available and affordable, consider an add-on Type 2 targeted biologic for patients with exacerbations and/or poor
symptom control despite taking at least high-dose ICS-LABA, and who have allergic or eosinophilic biomarkers or need
maintenance OCS. Where relevant, test for parasitic infection, and treat if present, before commencing treatment (see
section 5).
Consider whether to start first with anti-IgE, anti-IL5/5R, anti-IL4Rα or anti-TSLP. When choosing between
available therapies, consider the following:
• Does the patient satisfy local payer eligibility criteria?
• Type 2 comorbidities such as atopic dermatitis, nasal polyps
• Predictors of asthma response (see below)
• Cost
• Dosing frequency

132 3. Treating to control symptoms and minimize future risk

 • Delivery route (IV or SC; potential for self-administration)
• Patient preference.
Always check local payer eligibility criteria for biologic therapy, as they may vary substantially. However, GINA
recommends the use of biologic therapy only for patients with severe asthma, and only after treatment has been
optimized. For any biologic therapy, ensure that the manufacturer’s and/or regulator’s instructions for storage,
administration and the duration of monitoring post-administration are followed.
Provide the patient with advice about what to do if they experience any adverse effects, including hypersensitivity
reactions. GINA suggests that the first dose of asthma biologic therapy should not be given on the same day as a
COVID-19 vaccine, so that adverse effects of either can be more easily distinguished.
There is an urgent need for head-to-head comparisons of different biologics in patients eligible for more than
one biologic.
Add-on anti-IgE for severe allergic asthma

TE
Regulatory approvals may include: omalizumab for ages ≥6 years, given by SC injection every 2–4 weeks, with dose

U
IB
based on weight and serum IgE. May also be indicated for nasal polyps and chronic spontaneous (idiopathic) urticaria.

TR
Self-administration may be an option. Check local regulatory and payer criteria, as they may differ from these.

IS
D
Mechanism: binds to Fc part of free IgE, preventing binding of IgE to FcƐR1 receptors, reducing free IgE and down-

R
regulating receptor expression.

O
PY
Eligibility criteria (in addition to criteria for severe asthma) vary between payers, but usually include:
O
C
• Sensitization to inhaled allergen(s) on skin prick testing or specific IgE, and
T
O

• Total serum IgE and body weight within local dosing range, and
N

More than a specified number of exacerbations within the last year.

O

•
-D

Outcomes: Meta-analysis of RCTs in severe allergic asthma: 44% decrease in severe exacerbations; improved quality
L
IA

of life.294 No double-blind randomized controlled trials of OCS-sparing effect. In a meta-analysis of observational studies
ER

in patients with severe allergic asthma, there was a 59% reduction in exacerbation rate, a 41% reduction in the
AT

proportion of patients receiving maintenance OCS, and a significant improvement in symptom control.598 In patients with
M

nasal polyps, omalizumab improved subjective and objective outcomes.512 Additional details about treatment of chronic
D

rhinosinusitis with nasal polyps (CRSwNP) are found on p.108. A registry study of omalizumab in pregnancy found no
TE

increased risk of congenital malformations.548

H
IG

Potential predictors of good asthma response to omalizumab:

R
PY

• Baseline IgE level does not predict likelihood of response599

O
C

• In a post-hoc analysis of one clinical trial, a greater decrease in exacerbations was observed (cf. placebo) with
blood eosinophils ≥260/μl600,601 or FeNO ≥19.5 ppb600 (these criteria representing their median value in that
study) but in two large observational studies, exacerbations were reduced with both low or high blood
eosinophils602-604 or with both low or high FeNO.604
• Childhood-onset asthma
• Clinical history suggesting allergen-driven symptoms.
Adverse effects: injection site reactions; anaphylaxis in approximately 0.2% patients605
Suggested initial trial: at least 4 months
Add-on anti-IL5 or anti-IL5R for severe eosinophilic asthma
Regulatory approvals may include: For ages ≥12 years: mepolizumab (anti-IL5), 100 mg by SC injection every 4 weeks,
or benralizumab (anti-IL5 receptor α), 30 mg by SC injection every 4 weeks for 3 doses then every 8 weeks. For ages

3. Treating to control symptoms and minimize future risk 133

 ≥18 years: reslizumab (anti-IL5), 3 mg/kg by IV infusion every 4 weeks. For ages 6–11 years, mepolizumab (anti-IL5),
40 mg by SC injection every 4 weeks. Mepolizumab may also be indicated for eosinophilic granulomatosis with
polyangiitis (EGPA), hypereosinophilic syndrome and chronic rhinosinusitis with nasal polyps. Self-administration may
be an option. Check local regulatory and payer criteria, as they may differ from these.
Mechanism: mepolizumab and reslizumab bind circulating IL-5; benralizumab binds to IL-5 receptor alpha subunit
leading to apoptosis (cell death) of eosinophils.
Eligibility criteria (in addition to criteria for severe asthma): these vary by product and between payers, but usually
include:
• More than a specified number of severe exacerbations in the last year, and
• Blood eosinophils above locally specified level (e.g., ≥150 or ≥300/μl). There is sometimes a different eosinophil
cut-point for patients taking OCS.
Outcomes: Meta-analysis of RCTs in severe asthma patients with exacerbations in the last year, with varying eosinophil

TE
criteria: anti-IL5 and anti-IL5R led to 47–54% reduction in severe exacerbations. Improvements in quality of life, lung

U
function and symptom control were significant,294 but less than the clinically important difference. All reduced blood

IB
eosinophils; almost completely with benralizumab.606 In post hoc analyses, clinical outcomes with mepolizumab or

TR
benralizumab were similar in patients with and without an allergic phenotype.607,608 In patients taking OCS, median OCS

IS
D
dose was able to be reduced by approximately 50% with mepolizumab609 or benralizumab297 compared with placebo. .

R
In urban children aged 6 years and older with eosinophilic exacerbation-prone asthma, an RCT showed a reduction in

O
the number of exacerbations with subcutaneous mepolizumab versus placebo.298 No differences were seen in lung
PY
function, a composite asthma score (CASI), or physician–patient global assessment.298 In patients with nasal polyps,
O
C
mepolizumab improved subjective and objective outcomes and reduced the need for surgery,513,514 and in patients with
T

nasal polyps and severe eosinophilic asthma, benralizumab improved subjective outcomes for both conditions and
O
N

improved quality of life.610 Additional details about treatment of nasal polyps are found on p.108.
O
-D

Potential predictors of good asthma response to anti-IL5 or anti-IL5R:

L
IA

• Higher blood eosinophils (strongly predictive)611

ER

• Higher number of severe exacerbations in previous year (strongly predictive)611

AT

• Adult-onset asthma612
M
D

• Nasal polyps608
TE

• Maintenance OCS at baseline608

H
IG

• Low lung function (FEV1 <65% predicted in one study).613

R
PY

Adverse effects: In adults, injection site reactions; anaphylaxis rare; adverse events generally similar between active and
O

placebo. In children, more skin/subcutaneous tissue and nervous system disorders (e.g., headache, dizziness, syncope)
C

were seen with mepolizumab than placebo.298

Suggested initial trial: at least 4 months
Add-on anti-IL4Rα for severe eosinophilic/Type 2 asthma or patients requiring maintenance OCS
Regulatory approvals may include: For ages ≥12 years: dupilumab (anti-IL4 receptor α), 200 mg or 300 mg by SC
injection every 2 weeks for severe eosinophilic/Type 2 asthma; 300 mg by SC injection every 2 weeks for OCS-
dependent severe asthma or if there is concomitant moderate/severe atopic dermatitis. For children 6–11 years with
severe eosinophilic/Type 2 asthma by SC injection with dose and frequency depending on weight. May also be indicated
for treatment of skin conditions including moderate-to-severe atopic dermatitis, chronic rhinosinusitis with nasal polyps
and eosinophilic esophagitis. Self-administration may be an option. Check local regulatory and payer criteria, as they
may differ from these.
Mechanism: binds to interleukin-4 (IL-4) receptor alpha, blocking both IL-4 and IL-13 signaling

134 3. Treating to control symptoms and minimize future risk

 Eligibility criteria (in addition to criteria for severe asthma): these vary between payers, but usually include:
• More than a specified number of severe exacerbations in the last year, and
• Type 2 biomarkers above a specified level (e.g., blood eosinophils ≥150/μl and ≤1500/μl; or FeNO ≥25 ppb); OR
requirement for maintenance OCS
Outcomes: Meta-analysis of RCTs in patients with uncontrolled severe asthma (ACQ-5 ≥1.5) and at least one
exacerbation in the last year: anti-IL4Rα led to 56% reduction in severe exacerbations; improvements in quality of life,
symptom control and lung function were significant,303 but less than the clinically important difference. In a post hoc
analysis, clinical outcomes were similar in patients with allergic and non-allergic phenotype at baseline.614 In patients
with OCS-dependent severe asthma, without minimum requirements for blood eosinophil count or FeNO, the median
reduction in OCS dose with anti-IL4Rα versus placebo was 50%.615 In follow-up, changes were maintained through 2
years of follow-up.616 In children 6–11 years with eosinophilic/Type 2 asthma, dupilumab reduced severe exacerbation
rate and increased lung function; children taking maintenance OCS were excluded.300 In patients with chronic
rhinosinusitis with nasal polyps, dupilumab reduced the size of nasal polyps, improved nasal symptoms and reduced the

TE
need for OCS or sinus surgery.515,617 Additional details about nasal polyps are found on p.108.

U
IB
Potential predictors of good asthma response to dupilumab:

TR
• Higher blood eosinophils (strongly predictive)301

IS
D
• Higher FeNO (strongly predictive)301

R
O
Adverse effects: injection-site reactions; transient blood eosinophilia; rare cases of eosinophilic granulomatosis with

PY
polyangiitis (EGPA). Anti-IL4Rα is not suggested for patients with baseline or historic blood eosinophils >1,500 cells/µL
O
because of limited evidence (such patients were excluded from Phase III trials).
C
T

Suggested initial trial: at least 4 months

O
N
O

Add-on anti-TSLP for severe asthma

-D

Regulatory approvals may include: For ages ≥12 years: tezepelumab (anti-TSLP), 210 mg by SC injection every 4
L
IA

weeks. Self-administration may be an option. Check local regulatory and payer criteria, as they may differ from these.
ER

Mechanism: tezepelumab binds circulating TSLP, a bronchial epithelial cell-derived alarmin implicated in multiple
AT

downstream processes involved in asthma pathophysiology.

M
D

Eligibility criteria (in addition to criteria for severe asthma): these vary between payers, but usually include:
TE
H

• Severe exacerbations in the last year.

IG
R

Anti-TSLP may also be considered in patients with no elevated T2 markers (section 7.1)
PY
O

Outcomes: In two RCTs in severe asthma patients with severe exacerbations in the last year, anti-TSLP led to 30–70%
C

reduction in severe exacerbations, and improved quality of life, lung function and symptom control, irrespective of
allergic status.304,618 There was a clear correlation between higher baseline blood eosinophils or FeNO and better clinical
outcomes.618 In patients taking maintenance OCS, anti-TSLP did not lead to a reduced OCS dose compared with
placebo.619
Potential predictors of good asthma response to anti-TSLP:
• Higher blood eosinophils (strongly predictive)
• Higher FeNO levels (strongly predictive)
Adverse effects: injection site reactions; anaphylaxis is rare; adverse events generally similar between active and
placebo groups
Suggested initial trial: at least 4 months

3. Treating to control symptoms and minimize future risk 135

Review response to an initial trial of add-on Type 2-targeted therapy
• At present, there are no well-defined criteria for a good response, but consider exacerbations, symptom control,
lung function, side-effects, treatment intensity (including OCS dose), and patient satisfaction
• If the response is unclear, consider extending the trial to 6–12 months
• If there is no response, stop the biologic therapy, and consider switching to a trial of a different Type 2-targeted
therapy, if available and the patient is eligible. Also consider the patient’s biomarkers (interval and during
exacerbations, if available), and response of any comorbid Type 2 conditions (atopic dermatitis, nasal polyps
etc). Review response as above.

MANAGE AND MONITOR SEVERE ASTHMA TREATMENT

9. REVIEW RESPONSE AND IMPLICATIONS FOR TREATMENT

Review response to add-on biologic therapy after 3–4 months, and every 3–6 months for ongoing care, including:

TE
• Asthma: symptom control, e.g., Asthma Control Test, Asthma Control Questionnaire (ACQ-5); frequency and

U
IB
severity of exacerbations (e.g., whether OCS were needed), lung function

TR
• Type 2 comorbidities, e.g. nasal polyps, atopic dermatitis

IS
D
• Medications: treatment intensity, including dose of OCS, side-effects, affordability

R
O
• Patient satisfaction
If the patient has had a good response to Type 2 targeted therapy:
PY
O
C
Re-evaluate the need for each asthma medication every 3–6 months, but do not completely stop inhaled therapy. Base
T
O

the order of reduction or cessation of add-on treatments on the observed benefit when they were started, patient risk
N

factors, medication side-effects, cost, and patient satisfaction.

O
-D

For oral treatments, consider gradually decreasing or stopping OCS first, because of their significant adverse effects.
L

Tapering in severe asthma may be supported by internet-based monitoring of symptom control and FeNO.620 Monitor
IA
ER

patients for risk of adrenal insufficiency, and provide patient and primary care physician with advice about the need for
AT

extra corticosteroid doses during injury, illness or surgery for up to 6 months after cessation of long-term OCS. Continue
M

to assess for presence of osteoporosis, and review need for preventative strategies including bisphosphonates.311
D
TE

For inhaled treatments, consider reducing the ICS dose after 3–6 months, but do not completely stop inhaled therapy.
H

Current consensus advice is to continue at least medium-dose ICS. Patients should be reminded of the importance of
IG

continuing their ICS-containing treatment.

R
PY

For biologic treatments, current consensus advice is that, generally, for a patient with a good response, a trial of
O

withdrawal of the biologic should not be considered until after at least 12 months of treatment, and only if asthma
C

remains well controlled on medium-dose ICS therapy, and (for allergic asthma) there is no further exposure to a
previous well-documented allergic trigger. There are few studies of cessation of biologic therapy,621,622 in these studies,
symptom control worsened and/or exacerbations recurred for many (but not all) patients after cessation of the biologic.
For example, in a double-blind randomized controlled trial, significantly more patients who stopped mepolizumab
experienced a severe exacerbation within 12 months compared with those who continued treatment. There was a small
increase in ACQ-5 but no significant difference between groups.623 Long-term safety of several biologics has been
reported up to 5 or more years.624-626
If the patient has NOT had a good response to any Type 2-targeted therapy:
Stop the biologic therapy
Review the basics for factors contributing to symptoms, exacerbations and poor quality of life (see Section 2):
diagnosis/differential diagnosis, inhaler technique, adherence, modifiable risk factors and triggers including smoking and

136 3. Treating to control symptoms and minimize future risk

 other environmental exposures at home or work, comorbidities including obesity, medication side-effects or drug
interactions, socio-economic and mental health issues.
Consider additional investigations (if not already done): high resolution chest CT; induced sputum to confirm
inflammatory phenotype, consider bronchoscopy for alternative or additional diagnoses, consider referral if available,
including for diagnosis of alternative conditions.
Reassess treatment options (if not already done), such as:
• Add-on low-dose azithromycin292,595 (adults only; first check sputum for atypical mycobacteria and check ECG
for long QTc (and re-check after a month on treatment); consider potential for antibiotic resistance)
• As last resort, consider add-on low-dose maintenance OCS, but implement strategies such as alternate-day
therapy and add-on bisphosphonates to minimize side-effects,311 and alert patient to the need for additional
corticosteroid therapy during illness or surgery.
• Consider bronchial thermoplasty (+ registry).

TE
Stop ineffective add-on therapies, but do not completely stop ICS

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IB
10. CONTINUE COLLABORATIVE OPTIMIZATION OF PATIENT CARE

TR
IS
Ongoing management of a patient with severe asthma involves a collaboration between the patient, the primary care

D
physician, specialist(s), and other health professionals, to optimize clinical outcomes and patient satisfaction.

R
O
Continue to review the patient every 3–6 months including:
PY
O
• Clinical asthma measures (symptom control; exacerbations; lung function)
C
T

• Comorbidities
O
N

• The patient's risk factors for exacerbations

O
-D

• Treatments (check inhaler technique and adherence; review need for add- on treatments; assess side-effects
including of OCS; optimize comorbidity management and non-pharmacologic strategies)
L
IA
ER

• The patient’s social and emotional needs.

AT

The optimal frequency and location of review (primary care physician or specialist) will depend on the patient’s asthma
M

control, risk factors and comorbidities, and their confidence in self-management, and may depend on local payer
D

requirements and availability of specialist physicians.

TE
H

Communicate regularly about:

IG
R

• Outcome of review visits (as above)

PY

• Patient concerns
O
C

• Action plan for worsening asthma or other risks

• Changes to medications (asthma and non-asthma); potential side-effects
• Indications and contact details for expedited review.

3. Treating to control symptoms and minimize future risk 137

C
O
PY
R
IG
H
TE
D
M
AT
ER
IA
L
-D
O
N
O
T
C
O
PY
O
R
D
IS
TR
IB
U
TE
 SECTION 1. ADULTS, ADOLESCENTS AND
CHILDREN 6 YEARS AND OLDER

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U
IB
TR
IS
Chapter 4.

D
R
O
PY
O
C
T

Management of
O
N
O
-D

worsening asthma
L
IA
ER

and exacerbations
AT
M
D
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H
IG
R
PY
O
C
KEY POINTS

Terminology
• Exacerbations represent an acute or sub-acute worsening in symptoms and lung function from the patient’s
usual status, or in some cases, a patient may present for the first time during an exacerbation.
• The terms ‘episodes’, ‘attacks’ and ‘acute severe asthma’ are also often used, but they have variable
meanings. The term ‘flare-up’ is preferable for use in discussions with most patients.
• Patients who are at increased risk of asthma-related death should be identified, and flagged for more frequent
review.
Written asthma action plans
• All patients should be provided with a written (i.e., printed, digital or pictorial) asthma action plan appropriate for
their age, their current treatment regimen and their reliever inhaler (short-acting beta2 agonist [SABA] or
combination inhaled corticosteroids [ICS]-formoterol), their level of asthma control, and their health literacy, so

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they know how to recognize and respond to worsening asthma.

U
IB
• On the action plan, state when and how to change reliever and/or maintenance medications, use oral

TR
corticosteroids (OCS) if needed, and access medical care if symptoms fail to respond to treatment.

IS
D
• Advise patients who have a history of rapid deterioration to go to an acute care facility or see their doctor

R
immediately their asthma starts to worsen.

O
PY
• Base the action plan on changes in symptoms or (only in adults) peak expiratory flow (PEF).
O
C
Management of exacerbations in a primary care or acute care facility
T
O

• Assess exacerbation severity from the degree of dyspnea, respiratory rate, pulse rate, oxygen saturation and
N

lung function, while starting SABA and oxygen therapy. Infection control procedures should be followed.
O
-D

• Arrange immediate transfer to an acute care facility if there are signs of severe exacerbation, or to intensive
L

care if the patient is drowsy, confused, or has a silent chest. During transfer, give inhaled SABA and
IA
ER

ipratropium bromide, controlled oxygen and systemic corticosteroids.

AT

• Start treatment with repeated administration of SABA (in most patients, by pressurized metered-dose inhaler
M

[pMDI] and spacer), early introduction of oral corticosteroids, and controlled flow oxygen if available. Review
D

response of symptoms, oxygen saturation and lung function after 1 hour. Give ipratropium bromide only for
TE

severe exacerbations. Consider intravenous magnesium sulfate for patients with severe exacerbations not
H
IG

responding to initial treatment.

R
PY

• Do not routinely request a chest X-ray, and do not routinely prescribe antibiotics for asthma exacerbations.
O

• Decide about hospitalization based on the patient’s clinical status, lung function, response to treatment, recent
C

and past history of exacerbations, and ability to manage at home.

Discharge management
• Arrange ongoing treatment before the patient goes home. This should include starting ICS-containing controller
treatment or stepping up the dose of existing ICS-containing treatment for 2–4 weeks, and reducing reliever
medication to as-needed use.
• Arrange early follow-up after any exacerbation, regardless of where it was managed. At follow-up:
o Review the patient’s symptom control and risk factors for further exacerbations.
o Prescribe ICS-containing controller therapy to reduce the risk of further exacerbations. If already taking
ICS-containing therapy, continue increased doses for 2–4 weeks.
o Provide a written asthma action plan and, where relevant, advice about avoiding exacerbation triggers
• Check inhaler technique and adherence.

For management of asthma exacerbations in children 5 years and younger, see Chapter 6, p.187.

140 4. Management of worsening asthma and exacerbations

OVERVIEW

Definition of asthma exacerbations

Exacerbations of asthma are episodes characterized by a progressive increase in symptoms of shortness of breath,
cough, wheezing or chest tightness and progressive decrease in lung function, i.e. they represent a change from the
patient’s usual status that is sufficient to require a change in treatment.29 Exacerbations may occur in patients with a pre-
existing diagnosis of asthma or, occasionally, as the first presentation of asthma.

What triggers asthma exacerbations?

Exacerbations usually occur in response to exposure to an external agent (e.g. viral upper respiratory tract infection,
pollen or pollution) and/or poor adherence with ICS-containing medication; however, a subset of patients present more
acutely and without exposure to known risk factors.627,628 Severe exacerbations can occur in patients with mild or well-
controlled asthma symptoms.22,219 Box 2-2B (p.38) lists factors that increase a patient’s risk of exacerbations,

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independent of their level of symptom control.

U
IB
Common exacerbation triggers include:

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• Viral respiratory infections, 629 e.g. rhinovirus, influenza, adenovirus, pertussis, respiratory syncytial virus

IS
D
• Allergen exposure e.g., grass pollen,630 soybean dust,631 fungal spores

R
O
• Food allergy105

PY
• Outdoor air pollution111,112,632 O
• Seasonal changes and/or returning to school in fall (autumn)633
C

• Poor adherence with ICS634

T
O

• Epidemics of severe asthma exacerbations may occur suddenly, putting high pressure on local health system
N
O

responses. Such epidemics have been reported in association with springtime thunderstorms and either rye
-D

grass pollen or fungal spores,635 and with environmental exposure to soy bean dust.631
L
IA

Identifying patients at risk of asthma-related death

ER
AT

In addition to factors known to increase the risk of asthma exacerbations (Box 2-2, p.38), some features are specifically
M

associated with an increase in the risk of asthma-related death (Box 4-1). The presence of one or more of these risk
D

factors should be quickly identifiable in the clinical notes, and these patients should be encouraged to seek urgent
TE

medical care early in the course of an exacerbation.

H
IG
R

Box 4-1. Factors that increase the risk of asthma-related death

PY
O

• A history of near-fatal asthma requiring intubation and mechanical ventilation636

C

• Hospitalization636,637 or emergency care visit for asthma in the past year

• Currently using or having recently stopped using oral corticosteroids (a marker of event severity)636
• Not currently using inhaled corticosteroids101,636
• Over-use of short-acting beta2-agonists (SABAs), especially use of more than one canister of salbutamol (or
equivalent) monthly75,121,638
• Poor adherence with ICS-containing medications and/or poor adherence with (or lack of) a written asthma action
plan113
• A history of psychiatric disease or psychosocial problems113
• Food allergy in a patient with asthma499,639
• Several comorbidities including pneumonia, diabetes and arrhythmias were independently associated with an
increased risk of death after hospitalization for an asthma exacerbation.637
See list of abbreviations (p.10).

4. Management of worsening asthma and exacerbations 141

Terminology about exacerbations
The academic term ‘exacerbation’ is commonly used in scientific and clinical literature, although hospital-based studies
more often refer to ‘acute severe asthma’. However, the term ‘exacerbation’ is not suitable for use in clinical practice, as
it is difficult for many patients to pronounce and remember.640,641 The term ‘flare-up’ is simpler, and conveys the sense
that asthma is present even when symptoms are absent. The term ‘attack’ is used by many patients and health care
providers but with widely varying meanings, and it may not be perceived as including gradual worsening.640,641 In
pediatric literature, the term ‘episode’ is commonly used, but understanding of this term by parent/caregivers is not
known.

DIAGNOSIS OF EXACERBATIONS
Exacerbations represent a change in symptoms and lung function from the patient’s usual status.29 The decrease in
expiratory airflow can be quantified by lung function measurements such as PEF or forced expiratory volume in
1 second (FEV1),642 compared with the patient’s previous lung function or predicted values. In the acute setting, these

TE
measurements are more reliable indicators of the severity of the exacerbation than symptoms. The frequency of

U
symptoms may, however, be a more sensitive measure of the onset of an exacerbation than PEF.643 Consider the

IB
possibility of pertussis in a patient with an atypical exacerbation presentation, with predominant cough.

TR
IS
A minority of patients perceive airflow limitation poorly and can experience a significant decline in lung function without a

D
change in symptoms.136,148,156 This especially affects patients with a history of near-fatal asthma and also appears to be

R
O
more common in males. Regular PEF monitoring may be considered for such patients.

PY
Severe exacerbations are potentially life-threatening and their treatment requires careful assessment and close
O
C
monitoring. Patients with severe exacerbations should be advised to see their health care provider promptly or,
T

depending on the organization of local health services, to proceed to the nearest facility that provides emergency access
O
N

for patients with acute asthma.

O
-D

SELF-MANAGEMENT OF EXACERBATIONS WITH A WRITTEN ASTHMA ACTION PLAN

L
IA

All patients with asthma, and parents/caregivers of children with asthma, should be provided with guided self-
ER

management education as described in Chapter 3.3 (p.98). The definition of guided self-management education
AT

includes monitoring of symptoms and/or lung function, a written asthma action plan, and regular review by a health
M

professional.471 (For children 5 years and younger, see Chapter 6, p.169). A written (i.e., documented) asthma action
D
TE

plan may be printed, digital, or pictorial, to suit the patient’s needs and literacy.
H
IG

A written asthma action plan helps patients to recognize and respond appropriately to worsening asthma. It should
R

include specific instructions for the patient about changes to reliever and/or maintenance medications, when and how to
PY

use OCS if needed (Box 4-2) and when and how to access medical care.
O
C

The criteria for initiating an increase in maintenance medication will vary from patient to patient. In studies that evaluated
an increase in maintenance ICS-containing treatment, this was usually initiated when there was a clinically important
change from the patient’s usual level of asthma control, for example, if asthma symptoms were interfering with normal
activities, or PEF had fallen by >20% for more than 2 days.476
For patients prescribed an anti-inflammatory reliever (as-needed combination ICS-formoterol or ICS-SABA), this
provides a small extra dose of ICS as well as a rapid-acting bronchodilator without delay whenever the reliever is used,
as the first step in the patient’s action plan; this approach reduces the risk of progressing to severe exacerbation and
need for oral corticosteroids. In the case of as-needed ICS-formoterol, both the ICS and the formoterol appear to
contribute to the reduction in severe exacerbations compared with using a SABA reliever.229 See Box 3-15 (p.80) for
more details about as-needed ICS-formoterol, including medications and dosages.
A specific action plan template is available for patients prescribed maintenance and reliever therapy with ICS-
formoterol;8 it can also be modified for patients prescribed as-needed-only ICS-formoterol.

142 4. Management of worsening asthma and exacerbations

Treatment options for written asthma action plans – relievers
Inhaled combination ICS-formoterol reliever
In adults and adolescents, use of as-needed combination low-dose ICS-formoterol for symptom relief (without
maintenance treatment) reduced the risk of severe exacerbations requiring OCS or requiring emergency department
visit or hospitalization by 65% compared with SABA-only treatment,167. It also reduced the risk of needing an emergency
department visit or hospitalization by 37% compared with daily ICS plus as-needed SABA.167 After a day of even small
increased doses of ICS-formoterol, the risk of severe exacerbation in the following 3 weeks was reduced compared with
using the same doses of SABA alone.79 Details about the evidence are found on p.68 and p.71.
In adults, adolescents and children 6–11 years, maintenance-and-reliever therapy (MART) with ICS-formoterol reduced
the risk of severe exacerbations compared with the same or higher dose of ICS or ICS-LABA, with similar symptom
control.213,245,268 Details about the evidence are found on p.74 and p.76.
Information about medications and doses for use of as-needed ICS-formoterol is summarized in Box 3-15, p.80. For

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adults and adolescents, the evidence is with use of budesonide-formoterol 200/6 mcg metered dose (160/4.5 mcg

U
delievered dose) by dry powder inhaler and, for children aged 6–11 prescribed MART, budesonide-formoterol 100/6 mcg

IB
metered dose (80/4.5 mcg delivered dose) by dry powder inhaler. Patients prescribed ICS-formoterol as their reliever

TR
(with or without maintenance ICS-formoterol) should take 1 inhalation of their ICS-formoterol reliever whenever needed

IS
for symptom relief. If necessary, an extra dose can be taken a few minutes later. Additional doses are taken when

D
R
symptoms recur, even if this is within 4 hours, but the maximum total recommended dose in any single day for adults

O
and adolescents is 12 inhalations for budesonide-formoterol (total 72 mcg formoterol [54 mcg delivered dose]) and
PY
8 inhalations for budesonide-formoterol in children and for beclometasone-formoterol in adults (48 mcg formoterol [36
O
C
mcg delivered dose]). This is the maximum total of as-needed doses and maintenance doses, if used.
T
O

If the patient is rapidly worsening, or has failed to respond to an increase in as-needed doses of ICS-formoterol over
N

2–3 days, they should contact their healthcare provider or seek medical assistance.
O
-D

Inhaled combination ICS-SABA reliever

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For adults prescribed as-needed combination ICS-SABA reliever with maintenance ICS-containing therapy, the
ER

recommended dose is 2 inhalations of budesonide-salbutamol [albuterol] 100/100 mcg metered dose (80/90 mcg
AT

delivered dose) as needed, a maximum of 6 times in a day. Overall, in patients on Step 3–5 therapy, this reduced the
M

risk of severe exacerbations by 26% compared with using a SABA reliever, with the greatest benefit seen in patients
D
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taking maintenance low dose ICS-LABA or medium-dose ICS.259 There is only limited evidence about use of as-needed
H

ICS-SABA alone, i.e. without maintenance ICS or ICS-LABA (see p.73).

IG
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If the patient is rapidly worsening, or is needing repeated doses of as-needed ICS-SABA reliever over 1–2 days, they
PY

should contact their healthcare provider or seek medical assistance.

O
C

Inhaled SABA reliever

For patients prescribed a SABA bronchodilator reliever, repeated dosing provides temporary relief until the cause of the
worsening symptoms passes or increased ICS-containing treatment has had time to take effect. However, use of SABA
reliever is less effective in preventing progression to severe exacerbation requiring OCS than use of low-dose
ICS-formoterol reliever, either with213 or without202,203 daily maintenance ICS-containing treatment, or than combination
ICS-SABA reliever (see Chapter 3).
The need for repeated doses of SABA over more than 1–2 days signals the need to review, and possibly increase,
ICS-containing treatment if this has not already been done. This is particularly important if there has been a lack of
response.

4. Management of worsening asthma and exacerbations 143

Treatment options for written asthma action plans – maintenance medications
Maintenance and reliever therapy (MART) with combination low-dose ICS-formoterol
In adults and adolescents, the combination of a rapid-onset LABA (formoterol) and low-dose ICS (budesonide or
beclometasone) in a single inhaler as both the maintenance and the reliever medication was effective in improving
asthma symptom control,644 and it reduced exacerbations requiring OCS, and hospitalizations213,245-248 compared with
the same or higher dose of ICS or ICS-LABA with as-needed SABA reliever (Evidence A). This regimen was also
effective in reducing exacerbations in children aged 4–11 years (Evidence B).268
For adults and adolescents prescribed MART, the recommended maximum total dose of formoterol in 24 hours with
budesonide-formoterol is 72 mcg (delivered dose 54 mcg) and with beclometasone-formoterol is 48 mcg (delivered dose
36 mcg) (See Box 3-15, p.80). This approach should not be attempted with other combination ICS-LABA medications
with a slower-onset LABA, or that lack evidence of efficacy and safety with a maintenance and reliever regimen.
The benefit of the MART regimen in reducing the risk of severe exacerbations requiring OCS appears to be due to the

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increase in doses of both the ICS and the formoterol at a very early stage of worsening asthma.77-79

U
In an action plan for patients prescribed maintenance and reliever therapy with ICS-formoterol, the maintenance dose

IB
TR
does not normally need to be increased. Instead, the patient increases their as-needed doses of ICS-formoterol. More

IS
details of medications and doses for different age-groups are available in Box 3-15, p.80. Examples of action plans

D
customized for MART are available online.8,312

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O
Other ICS and ICS-LABA maintenance treatment regimens plus as-needed SABA
PY
O
In a systematic review, self-management studies in which the ICS dose was at least doubled were associated with
C
improved asthma outcomes and reduced health care utilization (Evidence A).476 In placebo-controlled trials, temporarily
T
O

doubling the dose of ICS was not effective (Evidence A);645 however, the delay before increasing the ICS dose (mean 5–
N

7 days646,647) may have contributed. Some studies in adults648 and young children649 have reported that higher ICS
O
-D

doses might help prevent worsening asthma progressing to a severe exacerbation. In a randomized controlled trial in
primary care with patients aged ≥16 years, those who quadrupled their ICS dose (to average of 2000 mcg/day
L
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beclometasone dipropionate (BDP) equivalent) after their PEF fell were significantly less likely to require OCS.650 In an
ER

open-label primary care randomized controlled trial of adult and adolescent patients using ICS with or without LABA,
AT

early quadrupling of ICS dose (to average 3200 mcg/day BDP equivalent) was associated with a modest reduction in
M

prescribing of OCS.651 However, a double-blind placebo-controlled study in children 5–11 years with high adherence to
D
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low-dose ICS found no difference in the rate of severe exacerbations requiring OCS if maintenance ICS was quintupled
H

(to 1600 mcg BDP equivalent) versus continuing maintenance low-dose therapy.652 Given the shape of the ICS dose-
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response curve, little benefit may be seen from increasing maintenance ICS when background adherence is high, as in
R
PY

this study.
O
C

In addition, in several of the studies evaluating ICS increases,646,647,652 a pre-specified level of deterioration in symptoms
(± lung function) had to be reached before the extra ICS could be started. This may help to explain the greater reduction
in severe exacerbations seen with maintenance and reliever therapy with ICS-formoterol, where there is no lag before
the doses of both ICS and formoterol are increased.
In adult with an acute deterioration, high-dose ICS for 7–14 days (500–1600 mcg BDP-HFA equivalent) had an
equivalent benefit to a short course of OCS (Evidence A).648 For adults taking combination ICS-LABA with as-needed
SABA, the ICS dose may be increased by adding a separate ICS inhaler (Evidence D).648,651
Leukotriene receptor antagonists
For patients with mild asthma using a leukotriene receptor antagonist (LTRA) as their controller, there are no specific
studies about how to manage worsening asthma. Clinicians’ judgment should be used (Evidence D).

144 4. Management of worsening asthma and exacerbations

Oral corticosteroids
For most patients, the written asthma action plan should provide instructions for when and how to commence OCS.
Typically, a short course of OCS is used (e.g. for adults, 40–50 mg/day usually for 5–7 days,648 Evidence B) for patients
who:
• Fail to respond to an increase in reliever and ICS-containing maintenance medication for 2–3 days
• Deteriorate rapidly or who have a PEF or FEV1 <60% of their personal best or predicted value
• Have worsening asthma and a history of sudden severe exacerbations.
For children 6–11 years, the recommended dose of prednisone is 1–2 mg/kg/day to a maximum of 40 mg/day (Evidence
B), usually for 3–5 days. Patients should be advised about common side-effects, including sleep disturbance, increased
appetite, reflux, and mood changes.653 Patients should contact their doctor if they start taking OCS (Evidence D).

Optimize asthma treatment to minimize the risk of exacerbations and the adverse effects of OCS
• OCS can be life-saving during severe asthma exacerbations, but there is increasing awareness of the risks of

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repeated courses.

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• In adults, short-term adverse effects of OCS include sleep disturbance, increased appetite, reflux, mood

TR
changes,653 sepsis, pneumonia, and thromboembolism.526

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• In adults, even 4–5 lifetime courses of OCS are associated with a significantly increased dose-dependent risk

D
of diabetes, cataract, heart failure, osteoporosis and several other conditions.309

R
O
• The need for OCS can be reduced by optimizing inhaled therapy, including attention to inhaler technique and

PY
adherence. O
C
• For adults and adolescents, GINA Track 1 with ICS-formoterol as anti-inflammatory reliever reduces the risk of
T

severe exacerbations requiring OCS compared with using a SABA reliever (see Box 3-12, p.65).
O
N
O
-D

Reviewing response
L

Patients should see their doctor immediately or go to an acute care unit if their asthma continues to deteriorate despite
IA
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following their written asthma action plan, or if their asthma suddenly worsens.
AT

Follow up after a self-managed exacerbation

M
D

After a self-managed exacerbation, patients should see their primary care health care provider for a semi-urgent review
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(e.g. within 1–2 weeks, but preferably before ceasing oral corticosteroids if prescribed), for assessment of symptom
H
IG

control and additional risk factors for exacerbations (Box 2-2, p.38), and to identify the potential cause of the
R
PY

exacerbation. This visit provides an opportunity for additional asthma education by a trained asthma educator or trained
lay healthcare worker.
O
C

The written asthma action plan should be reviewed to see if it met the patient’s needs. Maintenance asthma treatment
can generally be reduced to previous levels 2–4 weeks after the exacerbation (Evidence D), unless the history suggests
that the exacerbation occurred on a background of long-term poorly controlled asthma. In this situation, provided inhaler
technique and adherence have been checked, a step up in treatment may be indicated (Box 3-12, p.65).
Patients with more than 1–2 exacerbations per year despite Step 4–5 therapy (or Step 4 therapy in children 6–11 years),
or with several emergency department visits, should be referred to a specialist center, if available, for assessment and
strategies to reduce their risk of future exacerbations and their risk of exposure to OCS. See decision tree for difficult-to-
treat and severe asthma in Chapter 3.5, p.120.

4. Management of worsening asthma and exacerbations 145

 Box 4-2. Self-management of worsening asthma in adults and adolescents with a written asthma action plan

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U
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TR
IS
D
Medication Short-term change (1–2 weeks) for worsening asthma Evidence level

R
O
Increase usual reliever:
Low-dose ICS-formoterol † PY
Increase frequency of as-needed low-dose ICS-formoterol (for patients A
O
C
prescribed this as-needed only, or with maintenance ICS-formoterol). †
T

See Box 3-15 (p.80) for details of medications and doses.

O
N

Short-acting beta2-agonist Increase frequency of SABA use A

O

(SABA) For pMDI, add spacer A

-D

Combination ICS-SABA Increase frequency of as-needed ICS-SABA# (see p.143) B

L
IA
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Increase usual maintenance

treatment:
AT

Maintenance and reliever ICS- Continue usual maintenance dose of ICS-formoterol and increase reliever A
M

formoterol (MART)† ICS-formoterol as needed.† See Box 3-15 (p.80) for details.
D
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Maintenance ICS Consider quadrupling ICS dose. B

H

with SABA as reliever

IG
R

Maintenance ICS-formoterol Consider quadrupling maintenance ICS-formoterol.† B

PY

with SABA as reliever †

O
C

Maintenance ICS plus other Step up to higher dose formulation of ICS plus other LABA, if available B
LABA with SABA as reliever In adults, consider adding a separate ICS inhaler to quadruple ICS dose. D

Add oral corticosteroids (OCS) and contact doctor; review before ceasing
OCS (prednisone or Add OCS for severe exacerbations (e.g., PEF or FEV1 <60% personal best A
prednisolone) or predicted), or patient not responding to treatment over 48 hours. Once
started, morning dosing is preferable.
Adults: prednisolone* 40-50 mg/day, usually for 5–7 days. D
Tapering is not needed if OCS are prescribed for less than 2 weeks. B

See list of abbreviations (p.10). Options in each section are listed in order of evidence. *or equivalent dose of prednisone. † ICS-formoterol as-needed
for relief of symptoms in mild asthma (‘AIR-only’), or as part of maintenance and reliever therapy (MART) with low-dose combination budesonide or
beclometasone with formoterol. See Box 3-15, p.80 for details of medications and doses with ICS-formoterol. The maximum recommended dose in a
single day for adults and adolescents is a total of 12 inhalations of budesonide-formoterol (72 mcg formoterol, 54 mcg delivered dose) or 8 inhalations
of beclometasone-formoterol (48 mcg formoterol, 36 mcg delivered dose). # Combination budesonide-salbutamol (albuterol) 2 puffs of 100/100 mcg
(delivered dose 80/90 mcg) maximum 6 times in a day.259 See text for action plan options in children.

146 4. Management of worsening asthma and exacerbations

MANAGEMENT OF ASTHMA EXACERBATIONS IN PRIMARY CARE (ADULTS, ADOLESCENTS, CHLDREN 6–11
YEARS)

Assessing exacerbation severity

A brief focused history and relevant physical examination should be conducted concurrently with the prompt initiation of
therapy, and findings documented in the notes. If the patient shows signs of a severe or life-threatening exacerbation,
treatment with SABA, controlled oxygen and systemic corticosteroids should be initiated while arranging for the patient’s
urgent transfer to an acute care facility where monitoring and expertise are more readily available. Milder exacerbations
can usually be treated in a primary care setting, depending on resources and expertise.
History
The history should include:
• Timing of onset and cause (if known) of the present exacerbation
• Severity of asthma symptoms, including any limiting exercise or disturbing sleep

TE
• Any symptoms of anaphylaxis

U
IB
• Any risk factors for asthma-related death (Box 4-1, p.141)

TR
• All current reliever and maintenance medications, including doses and devices prescribed, adherence pattern, any

IS
recent dose changes, and response to current therapy.

D
R
Physical examination

O
PY
The physical examination should assess: O
C
• Signs of exacerbation severity (Box 4-3, p.148) and vital signs (e.g., level of consciousness, temperature, pulse
T

rate, respiratory rate, blood pressure, ability to complete sentences, use of accessory muscles, wheeze).
O
N

• Complicating factors (e.g., anaphylaxis, pneumonia, pneumothorax)

O

• Signs of alternative conditions that could explain acute breathlessness (e.g., cardiac failure, inducible laryngeal
-D

obstruction, inhaled foreign body or pulmonary embolism).

L
IA

Objective measurements
ER
AT

• Pulse oximetry. Saturation levels <90% in children or adults signal the need for aggressive therapy. The FDA has
M

issued a safety communication alerting healthcare professionals to the fact that, under conditions of hypoxemia,
D

oxygen saturation may be over-estimated by pulse oximeters in people with dark skin color.654
TE

• PEF in patients older than 5 years (Box 4-3, p.148)

H
IG
R

Treating exacerbations in primary care

PY
O

The main initial therapies include repetitive administration of rapid-acting inhaled bronchodilators, early introduction of
C

systemic corticosteroids, and controlled flow oxygen supplementation.642 The aim is to rapidly relieve airflow obstruction
and hypoxemia, address the underlying inflammatory pathophysiology, and prevent relapse. Infection control procedures
should be followed.
Inhaled short-acting beta2-agonists
Currently, inhaled salbutamol (albuterol) is the usual bronchodilator for acute asthma management. For mild to
moderate exacerbations, repeated administration of inhaled SABA (up to 4–10 puffs every 20 minutes for the first hour)
is an effective and efficient way to achieve rapid reversal of airflow limitation655 (Evidence A). After the first hour, the
dose of SABA required varies from 4–10 puffs every 3–4 hours up to 6–10 puffs every 1–2 hours, or more often. No
additional SABA is needed if there is a good response to initial treatment (e.g. PEF >60–80% of predicted or personal
best for 3–4 hours).

4. Management of worsening asthma and exacerbations 147

 Box 4-3. Management of asthma exacerbations in primary care (adults, adolescents, children 6–11 years)

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10).

148 4. Management of worsening asthma and exacerbations

 Delivery of SABA via a pMDI and spacer or a DPI leads to a similar improvement in lung function as delivery via
nebulizer (Evidence A);655,656 however, patients with acute severe asthma were not included in these studies. The most
cost-effective route of delivery is pMDI and spacer,657 provided the patient can use this device. Because of static charge,
some spacers require pre-washing with detergent before use. The manufacturer’s advice should be followed.
Combination ICS-formoterol in management of acute asthma exacerbations
Combination ICS-formoterol (budesonide-formoterol or beclometasone-formoterol) is now widely used as an
anti-inflammatory reliever as part of routine asthma management in adults and adolescents, because it reduces the risk
of severe exacerbations and exposure to OCS compared with use of a SABA reliever (GINA Track 1, p.58). Up to 12
inhalations of budesonide-formoterol 200/6 mcg (or 8 inhalations of beclometasone-formoterol 100/6) can be taken in a
single day if needed (see Box 3-15, p.80 for details of medications and doses).
In emergency departments, a randomized controlled trial in adult and adolescent patients with average FEV1 42–45%
predicted compared the effect of 2 doses of budesonide-formoterol 400/12 mcg (delivered dose 320/9 mcg) versus 8
doses of salbutamol (albuterol) 100 mcg (delivered dose 90 mcg), with these doses repeated again after 5 minutes; all

TE
patients received OCS. Lung function was similar over 3 hours, but pulse rate was higher in the SABA group658. A meta-

U
IB
analysis of earlier RCTs found that the efficacy and safety of formoterol itself was similar to that of salbutamol [albuterol]

TR
in management of acute asthma.659 Formoterol is no longer used for this purpose, but there is no evidence that

IS
budesonide-formoterol would be less effective in management of asthma exacerbations.659 More studies are needed.

D
There are no published data on use of combination ICS-SABA in an emergency department setting.

R
O
Controlled oxygen therapy (if available)
PY
O
Oxygen therapy should be titrated against pulse oximetry (if available) to maintain oxygen saturation at 93–95% (94–
C

98% for children 6–11 years); note the FDA caution above about potential overestimation of saturation in people with
T
O

dark skin color (p.147). In hospitalized asthma patients, controlled or titrated oxygen therapy is associated with lower
N

mortality and better outcomes than high concentration (100%) oxygen therapy660-663 (Evidence A). Oxygen should not be
O
-D

withheld if oximetry is not available, but the patient should be monitored for deterioration, somnolence or fatigue
L

because of the risk of hypercapnia and respiratory failure.660-663 If supplemental oxygen is administered, oxygen
IA

saturation should be maintained no higher than 96% in adults.664

ER
AT

Systemic corticosteroids
M

OCS should be given promptly, especially if the patient is deteriorating, or had already increased their reliever and
D
TE

maintenance ICS-containing medications before presenting (Evidence B). The recommended dose of prednisolone for
H

adults is 1 mg/kg/day or equivalent up to a maximum of 50 mg/day, and 1–2 mg/kg/day for children 6–11 years up to a
IG

maximum of 40 mg/day). OCS should usually be continued for 5–7 days in adults665,666 and 3-5 days in children667
R
PY

(Evidence B). Patients should be advised about common short-term side-effects, including sleep disturbance, increased
O

appetite, reflux and mood changes.653 In adults, the risk of sepsis and thromboembolism is also increased after a short
C

course of OCS.526 While OCS are life-saving for acute severe asthma, use of 4–5 lifetime courses in adults is associated
with a dose-dependent increased risk of long-term adverse effects such as osteoporosis, fractures, diabetes, heart
failure and cataract.309 This emphasizes the importance of optimizing asthma management after any severe
exacerbation to reduce the risk of further exacerbations (see Chapter 3.2, p.53).
Maintenance ICS-containing medication
Patients already prescribed maintenance ICS-containing medication should be provided with advice about increasing
the dose for the next 2–4 weeks, as summarized in Box 4-2 (p.146). Patients not currently taking controller medication
should be commenced on ICS-containing therapy, as SABA-only treatment of asthma is no longer recommended. An
exacerbation requiring medical care indicates that the patient is at increased risk of future exacerbations (Box 2-2, p.38).
Antibiotics (not recommended)
Evidence does not support routine use of antibiotics in the treatment of acute asthma exacerbations unless there is
strong evidence of lung infection (e.g. fever and purulent sputum or radiographic evidence of pneumonia).668

4. Management of worsening asthma and exacerbations 149

Reviewing response
During treatment, patients should be closely monitored, and treatment titrated according to their response. Patients who
present with signs of a severe or life-threatening exacerbation (Box 4-3, p.148), who fail to respond to treatment, or who
continue to deteriorate should be transferred immediately to an acute care facility. Patients with little or slow response to
SABA treatment should be closely monitored.
For many patients, lung function can be monitored after SABA therapy is initiated. Additional treatment should continue
until PEF or FEV1 reaches a plateau or (ideally) returns to the patient’s previous best. A decision can then be made
whether to send the patient home or transfer them to an acute care facility.

Follow up
Discharge medications should include regular maintenance ICS-containing treatment (see Box 3-15, p.80 and Box 4-5,
p.157), as-needed reliever medication (low-dose ICS-formoterol, ICS-SABA or SABA) and a short course of OCS.
SABA-only treatment is not recommended. Inhaler technique and adherence should be reviewed before discharge.

TE
Patients should be advised to use their reliever inhaler only as-needed, rather than routinely. A follow-up appointment

U
should be arranged for about 2–7 days later, depending on the clinical and social context.

IB
TR
At the review visit the health care provider should assess whether the flare-up has resolved, and whether OCS can be

IS
ceased. They should assess the patient’s level of symptom control and risk factors; explore the potential cause of the

D
R
exacerbation; and review the written asthma action plan (or provide one if the patient does not already have one).

O
Maintenance ICS-containing treatment can generally be stepped back to pre-exacerbation levels 2–4 weeks after the
PY
exacerbation. However, if the exacerbation was preceded by symptoms suggestive of chronically poorly controlled
O
C
asthma, and inhaler technique and adherence are good, a step up in treatment (Box 3-12, p.65) may be indicated.
T
O
N

MANAGEMENT OF ASTHMA EXACERBATIONS IN THE EMERGENCY DEPARTMENT (ADULTS, ADOLESCENTS,

O

CHILDREN 6–11 YEARS)

-D

Severe exacerbations of asthma are life-threatening medical emergencies, which are most safely managed in an acute
L
IA

care setting e.g., emergency department (Box 4-4). Infection control procedures should be followed. Management of
ER

asthma in the intensive care unit is beyond the scope of this report and readers are referred to a comprehensive
AT

review.669
M
D
TE

Assessment
H

History
IG
R
PY

A brief history and physical examination should be conducted concurrently with the prompt initiation of therapy. Include:
O

• Time of onset and cause (if known) of the present exacerbation

C

• Severity of asthma symptoms, including any limiting exercise or disturbing sleep

• Any symptoms of anaphylaxis
• Risk factors for asthma-related death (Box 4-1, p.141)
• All current reliever and maintenance medications, including doses and devices prescribed, adherence pattern, any
recent dose changes, and response to current therapy.
Physical examination
The physical examination should assess:
• Signs of exacerbation severity (Box 4-4), including vital signs (e.g., level of consciousness, temperature, pulse
rate, respiratory rate, blood pressure, ability to complete sentences, use of accessory muscles)
• Complicating factors (e.g., anaphylaxis, pneumonia, atelectasis, pneumothorax or pneumomediastinum)
• Signs of alternative conditions that could explain acute breathlessness (e.g., cardiac failure, inducible laryngeal
obstruction, inhaled foreign body or pulmonary embolism).

150 4. Management of worsening asthma and exacerbations

Objective assessments
Objective assessments are also needed as the physical examination alone may not indicate the severity of the
exacerbation.670,671 However, patients, and not their laboratory values, should be the focus of treatment.
• Measurement of lung function: this is strongly recommended. If possible, and without unduly delaying treatment,
PEF or FEV1 should be recorded before treatment is initiated, although spirometry may not be possible in children
with acute asthma. Lung function should be monitored at one hour and at intervals until a clear response to
treatment has occurred or a plateau is reached.
• Oxygen saturation: this should be closely monitored, preferably by pulse oximetry. In children, oxygen saturation
is normally ≥95% when breathing room air at sea level, and saturation <92% is a predictor of the need for
hospitalization (Evidence C).672 Saturation levels <90% in children or adults signal the need for aggressive
therapy. Subject to clinical urgency, saturation should be assessed before oxygen is commenced, or 5 minutes
after oxygen is removed or when saturation stabilizes. The FDA has issued a safety communication alerting
healthcare professionals to the fact that, under conditions of hypoxemia, oxygen saturation may be over-estimated
by pulse oximeters in people with dark skin color.654

TE
U
• Arterial blood gas measurements are not routinely required:673 They should be considered for patients with PEF or

IB
FEV1 <50% predicted,674 or for those who do not respond to initial treatment or are deteriorating. Supplemental

TR
controlled oxygen should be continued while blood gases are obtained. During an asthma exacerbation PaCO2 is

IS
often below normal (<40 mmHg). Fatigue and somnolence suggest that pCO2 may be increasing and airway

D
R
intervention may be needed. PaO2<60 mmHg (8 kPa) and normal or increased PaCO2 (especially >45 mmHg,

O
6 kPa) indicate respiratory failure.
• PY
Chest X-ray (CXR) is not routinely recommended: In adults, CXR should be considered if a complicating or
O
C
alternative cardiopulmonary process is suspected (especially in older patients), or for patients who are not
T

responding to treatment where a pneumothorax may be difficult to diagnose clinically.675 Similarly, in children,
O
N

routine CXR is not recommended unless there are physical signs suggestive of pneumothorax, parenchymal
O

disease or an inhaled foreign body. Features associated with positive CXR findings in children include fever, no
-D

family history of asthma, and localized lung examination findings.676

L
IA
ER

Treatment in acute care settings such as the emergency department

AT

The following treatments are usually administered concurrently to achieve rapid improvement.677
M
D

Oxygen
TE
H

To achieve arterial oxygen saturation of 93–95% (94–98% for children 6–11 years), oxygen should be administered by
IG

nasal cannulae or mask. Note the FDA caution above about potential overestimation of saturation in people with dark
R
PY

skin color (p.151). In severe exacerbations, controlled low flow oxygen therapy using pulse oximetry to maintain
O

saturation at 93–95% is associated with better physiological outcomes than with high concentration (100%) oxygen
C

therapy660-662 (Evidence B). However, oxygen therapy should not be withheld if pulse oximetry is not available (Evidence
D). Once the patient has stabilized, consider weaning them off oxygen using oximetry to guide the need for ongoing
oxygen therapy.
Inhaled short-acting beta2-agonists
Inhaled short-acting beta2-agonist (SABA) therapy such as salbutamol [albuterol] should be administered frequently for
patients presenting with acute asthma. The most cost-effective and efficient delivery is by pMDI with a spacer655,657
(Evidence A). Evidence is less robust in severe and near-fatal asthma. Systematic reviews of intermittent versus
continuous SABA in acute asthma, which mostly used nebulized SABA, provide conflicting results. Use of nebulizers
can disseminate aerosols and potentially contribute to spread of respiratory viral infections.678
Current evidence does not support the routine use of intravenous beta2-agonists in patients with severe asthma
exacerbations (Evidence A).679

4. Management of worsening asthma and exacerbations 151

 Box 4-4. Management of asthma exacerbations in acute care facility, e.g. emergency department

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10).

152 4. Management of worsening asthma and exacerbations

Combination ICS-formoterol as an alternative to high dose SABA
Currently, inhaled salbutamol (albuterol) is the usual bronchodilator in acute asthma management. Similar efficacy and
safety have been reported from emergency department studies with formoterol,659 and in one study with budesonide-
formoterol.658 This study showed that high-dose budesonide-formoterol had similar efficacy and safety profile to high
dose SABA.658 In this study, patients received 2 doses of budesonide-formoterol 400/12 mcg (delivered dose
320/9 mcg) or 8 doses of salbutamol (albuterol) 100 mcg (delivered dose 90 mcg), repeated once after 5 minutes; all
patients received OCS.658 While more studies are needed, meta-analysis of data from earlier studies comparing high-
dose formoterol with high dose salbutamol (albuterol) for treatment of acute asthma in the ED setting suggest that
budesonide-formoterol would also be effective.659 Formoterol alone is no longer used for this purpose.
Epinephrine (for anaphylaxis)
Intramuscular epinephrine (adrenaline) is indicated in addition to standard therapy for acute asthma associated with
anaphylaxis and angioedema. It is not routinely indicated for other asthma exacerbations.

TE
Systemic corticosteroids

U
IB
Systemic corticosteroids speed resolution of exacerbations and prevent relapse, and in acute care settings should be

TR
utilized in all but the mildest exacerbations in adults, adolescents and children 6–11 years.680,681 (Evidence A). Where

IS
possible, systemic corticosteroids should be administered to the patient within 1 hour of presentation.680,682 Use of

D
R
systemic corticosteroids is particularly important in the emergency department if:

O
• Initial SABA treatment fails to achieve lasting improvement in symptoms
• The exacerbation developed while the patient was taking OCS PY
O
C
• The patient has a history of previous exacerbations requiring OCS.
T
O

Route of delivery: oral administration is as effective as intravenous. The oral route is preferred because it is quicker, less
N
O

invasive and less expensive.683,684 For children, a liquid formulation is preferred to tablets. OCS require at least 4 hours
-D

to produce a clinical improvement. Intravenous corticosteroids can be administered when patients are too dyspneic to
L

swallow; if the patient is vomiting; or when patients require non-invasive ventilation or intubation. Evidence does not
IA
ER

demonstrate a benefit of intramuscular corticosteroids over oral corticosteroids.681

AT

Dosage: daily doses of OCS equivalent to 50 mg prednisolone as a single morning dose, or 200 mg hydrocortisone in
M

divided doses, are typically used for adults. For children, a prednisolone dose of 1–2 mg/kg up to a maximum of
D
TE

40 mg/day is suggested.685
H

Duration: 5- and 7-day courses in adults have been found to be as effective as 10- and 14-day courses respectively
IG
R

(Evidence B),665,666 and a 3–5-day course in children is usually considered sufficient for most. A small number of studies
PY

examined oral dexamethasone 0.6 mg/kg, given once daily for 1-2 days in children and adults; the relapse rate was
O

similar to that with prednisolone for 3–5 days, with a lower risk of vomiting.686-688 Oral dexamethasone should not be
C

continued beyond 2 days because of concerns about metabolic side-effects. If there is a failure of resolution, or relapse
of symptoms, consideration should be given to switching to prednisolone. Evidence from studies in which all patients
were taking maintenance ICS after discharge suggests that there is no benefit in tapering the dose of OCS, either in the
short term689 or over several weeks690 (Evidence B).
Inhaled corticosteroids
Within the emergency department: high-dose ICS given within the first hour after presentation reduces the need for
hospitalization in patients not receiving systemic corticosteroids (Evidence A).682 When added to systemic
corticosteroids, evidence is conflicting in adults.691 In children, administration of ICS with or without concomitant systemic
corticosteroids within the first hours of attendance to the emergency department might reduce the risk of hospital
admission and need for systemic corticosteroids (Evidence B).692 Overall, add-on ICS are well tolerated; however, cost
may be a significant factor, and the agent, dose and duration of treatment with ICS in the management of asthma in the
emergency department remain unclear. Patients admitted to hospital for an asthma exacerbation should continue on, or
be prescribed, ICS-containing therapy.

4. Management of worsening asthma and exacerbations 153

 On discharge home: patients should be prescribed ongoing ICS-containing treatment since the occurrence of a severe
exacerbation is a risk factor for future exacerbations (Evidence B) (Box 2-2, p.38), and ICS-containing medications
significantly reduce the risk of asthma-related death or hospitalization (Evidence A).221 SABA-only treatment of asthma
is no longer recommended. For short-term outcomes such as relapse requiring admission, symptoms, and quality of life,
a systematic review found no significant differences when ICS were added to systemic corticosteroids after discharge.693
There was some evidence, however, that post-discharge ICS were as effective as systemic corticosteroids for milder
exacerbations, but the confidence limits were wide (Evidence B).693 Cost may be a significant factor for patients in the
use of high-dose ICS, and further studies are required to establish their role.693
After an ED presentation or hospitalization, the preferred ongoing treatment is maintenance-and-reliver therapy (MART)
with ICS-formoterol. In patients with a history of ≥1 severe exacerbations, MART reduces the risk of another severe
exacerbation in the next 12 months by 32% compared with same dose ICS or ICS-LABA plus as-needed SABA, and by
23% compared with higher dose ICS-LABA plus as-needed SABA.213 See Box 3-15 (p.80) for medications and doses.
Other treatments

TE
Ipratropium bromide

U
IB
For adults and children with moderate-severe exacerbations, treatment in the emergency department with both SABA

TR
and ipratropium, a short-acting anticholinergic, was associated with fewer hospitalizations (Evidence A694 for adults;

IS
Evidence B695 for adolescents/children) and greater improvement in PEF and FEV1 compared with SABA alone

D
R
(Evidence A, adults/adolescents).694-696 For children hospitalized for acute asthma, no benefits were seen from adding

O
ipratropium to SABA, including no reduction in length of stay,695 but the risk of nausea and tremor was reduced.695
PY
O
Aminophylline and theophylline (not recommended)
C
T

Intravenous aminophylline and theophylline should not be used in the management of asthma exacerbations, in view of
O
N

their poor efficacy and safety profile, and the greater effectiveness and relative safety of SABA.697 Nausea and/or
O

vomiting are more common with aminophylline.695,697 The use of intravenous aminophylline is associated with severe
-D

and potentially fatal side-effects, particularly in patients already treated with sustained-release theophylline. In adults
L
IA

with severe asthma exacerbations, add-on treatment with aminophylline does not improve outcomes compared with
ER

SABA alone.697
AT

Magnesium
M
D

Intravenous magnesium sulfate is not recommended for routine use in asthma exacerbations; however, when
TE

administered as a single 2 g infusion over 20 minutes, it reduces hospital admissions in some patients, including adults
H
IG

with FEV1 <25–30% predicted at presentation; adults and children who fail to respond to initial treatment and have
R

persistent hypoxemia; and children whose FEV1 fails to reach 60% predicted after 1 hour of care (Evidence A).698-700
PY

Randomized, controlled trials that excluded patients with more severe asthma showed no benefit with the addition of
O
C

intravenous or nebulized magnesium compared with placebo in the routine care of asthma exacerbations in adults and
adolescents701-703 or children702,704 (Evidence B).
Helium oxygen therapy
A systematic review of studies comparing helium–oxygen with air–oxygen suggests there is no role for this intervention
in routine care (Evidence B), but it may be considered for patients who do not respond to standard therapy; however,
availability, cost and technical issues should be considered.705
Leukotriene receptor antagonists (LTRAs)
There is limited evidence to support a role for oral or intravenous LTRAs in acute asthma. Small studies have
demonstrated improvement in lung function706,707 but the clinical role and safety of these agents requires more study.
Antibiotics (not recommended)
Evidence does not support the routine use of antibiotics in the treatment of acute asthma exacerbations unless there is
strong evidence of lung infection (e.g. fever or purulent sputum or radiographic evidence of pneumonia).668

154 4. Management of worsening asthma and exacerbations

Non-invasive ventilation (NIV)
The evidence regarding the role of NIV in asthma is weak. A systematic review identified five studies involving
206 participants with acute severe asthma treated with NIV or placebo.708 Two studies found no difference in need for
endotracheal intubation but one study identified fewer admissions in the NIV group. No deaths were reported in either
study. Given the small size of the studies, no recommendation is offered. If NIV is tried, the patient should be monitored
closely (Evidence D). It should not be attempted in agitated patients, and patients should not be sedated in order to
receive NIV (Evidence D).
Sedatives (MUST BE AVOIDED)
Sedation should be strictly avoided during exacerbations of asthma because of the respiratory depressant effect of
anxiolytic and hypnotic drugs. An association between the use of these drugs and avoidable asthma deaths has been
reported.709,710

Reviewing response

TE
Clinical status and oxygen saturation should be re-assessed frequently, with further treatment titrated according to the

U
IB
patient’s response (Box 4-4, p.152). Lung function should be measured after one hour, i.e., after the first three

TR
bronchodilator treatments, and patients who deteriorate despite intensive bronchodilator and corticosteroid treatment

IS
should be re-evaluated for transfer to the intensive care unit.

D
R
Criteria for hospitalization versus discharge from the emergency department

O
PY
From retrospective analyses, clinical status (including the ability to lie flat) and lung function 1 hour after commencement
O
of treatment are more reliable predictors of the need for hospitalization than the patient’s status on arrival.711,712
C
T
O

Spirometric criteria proposed for consideration for admission or discharge from the emergency department include:713
N
O

• If pre-treatment FEV1 or PEF is <25% predicted or personal best, or post-treatment FEV1 or PEF is <40%
-D

predicted or personal best, hospitalization is recommended.

L

• If post-treatment lung function is 40–60% predicted, discharge may be possible after considering the patient’s risk
IA
ER

factors (Box 4-1, p.141) and availability of follow-up care.

If post-treatment lung function is >60% predicted or personal best, discharge is recommended after considering
AT

•
risk factors and availability of follow-up care.
M
D
TE

Other factors associated with increased likelihood of need for admission include:714-716
H

• Female sex, older age and non-white race

IG

• Use of more than eight beta2-agonist puffs in the previous 24 hours

R
PY

• Severity of the exacerbation (e.g., need for resuscitation or rapid medical intervention on arrival, respiratory rate
O

>22 breaths/minute, oxygen saturation <95%, final PEF <50% predicted)

C

• Past history of severe exacerbations (e.g., intubations, asthma admissions)

• Previous unscheduled office and emergency department visits requiring use of OCS.
Overall, these risk factors should be considered by clinicians when making decisions on admission/discharge for
patients with asthma managed in the acute care setting. The patient’s social circumstances should also be considered.

4. Management of worsening asthma and exacerbations 155

DISCHARGE PLANNING AND FOLLOW-UP
Prior to discharge from the emergency department or hospital to home, arrangements should be made for a follow-up
appointment within 2–7 days (1–2 days for children), and strategies to improve asthma management including
medications, inhaler skills and written asthma action plan, should be addressed (Box 4-5).316
All patients should be prescribed ongoing ICS-containing treatment to reduce the risk of further exacerbations. For
adults and adolescents, the preferred regimen after discharge is maintenance-and-reliever therapy (MART) with the anti-
inflammatory reliever ICS-formoterol, because this will reduce the risk of future severe exacerbations and reduce the
need for OCS compared with a regimen with a SABA reliever. In the context of a recent ED visit or hospitalization, it
would be appropriate to commence treatment with ICS-formoterol in adults and adolescents at Step 4. For medications
and doses, see Box 3-15 (p.80), The maintenance dose can be stepped down later, once the patient has fully recovered
and asthma has remained stable for 2–3 months (see Box 3-16, p.83).

Follow up after emergency department presentation or hospitalization for asthma

TE
Following discharge, the patient should be reviewed by their health care provider regularly over subsequent weeks until

U
good symptom control is achieved and personal best lung function is reached or surpassed. Incentives such as free

IB
TR
transport and telephone reminders improve primary care follow up but have shown no effect on long-term outcomes.316

IS
At follow-up, again ensure that the patient’s treatment has been optimized to reduce the risk of future exacerbations.

D
R
Consider switching to GINA Track 1 with the anti-inflammatory reliever ICS-formoterol, if not already prescribed. See

O
Box 3-15 (p.80) for medications and doses. Check and correct inhaler technique and adherence.
PY
O
Patients discharged following an emergency department presentation or hospitalization for asthma should be especially
C
targeted for an asthma education program, if one is available. Patients who were hospitalized may be particularly
T
O

receptive to information and advice about their illness. Health care providers should take the opportunity to review:
N
O

• The patient’s understanding of the cause of their asthma exacerbation

-D

• Modifiable risk factors for exacerbations (including, where relevant, smoking) (Box 3-17, p.85)
L

• The patient’s understanding of the purposes and correct uses of medications, including ICS-containing
IA
ER

maintenance treatment and anti-inflammatory reliever, if prescribed

AT

• The actions the patient needs to take to respond to worsening symptoms or peak flows.
M

After an emergency department presentation, comprehensive intervention programs that include optimization of asthma
D
TE

treatment, inhaler technique, and elements of self-management education (self-monitoring, written action plan and
H

regular review177) are cost effective and have shown significant improvement in asthma outcomes316 (Evidence B).
IG
R

Referral for expert advice should be considered for patients who have been hospitalized for asthma, or who have had
PY

several presentations to an acute care setting despite having a primary care provider. Follow-up by a specialist is
O
C

associated with fewer subsequent emergency department visits or hospitalizations and better asthma control.316

Optimize asthma treatment to minimize the risk of exacerbations and the adverse effects of OCS
• OCS can be life-saving during severe asthma exacerbations, but there is increasing awareness of the risks of
repeated courses.
• In adults, short-term adverse effects of OCS include sleep disturbance, increased appetite, reflux, mood
changes,653 sepsis, pneumonia, and thromboembolism.526
• In adults, even 4–5 lifetime courses of OCS are associated with a significantly increased dose-dependent risk of
diabetes, cataract, heart failure, osteoporosis and several other conditions.309
• The need for OCS can be reduced by optimizing inhaled therapy, including attention to inhaler technique and
adherence.
• For adults and adolescents, GINA Track 1 with ICS-formoterol as anti-inflammatory reliever reduces the risk of
severe exacerbations requiring OCS compared with using a SABA reliever (see Box 3-12, p.65).

156 4. Management of worsening asthma and exacerbations

 Box 4-5. Discharge management after hospital or emergency department care for asthma

Medications
Inhaled corticosteroid (ICS)-containing therapy
Initiate ICS prior to discharge, if not previously prescribed. Maintenance-and-reliever therapy with ICS-formoterol
(MART) is preferred as it reduces risk of future exacerbations compared with using a SABA reliever (see Box 3-15,
p.80). For adults/adolescents, start at MART at Step 4 on discharge (Box 3-16, Box 3-15). If prescribing an ICS
regimen with SABA reliever, step maintenance dose up for 2–4 weeks (Box 4-2, p.146). Emphasize good adherence.
Oral corticosteroids (OCS)
To reduce the risk of relapse, prescribe at least a 5–7 day course of OCS for adults (prednisolone or equivalent 40–50
mg/day) and 3–5 days for children (1–2 mg/kg/day to a maximum of 40 mg/day)717 (Evidence A). Review progress
before ceasing OCS. If the OCS is dexamethasone, treatment is only for total 1–2 days,686 but if there is failure of
resolution, or relapse of symptoms, consider switching to prednisolone.

TE
Reliever medication – return to as-needed rather than regular use

U
Transfer patients back to as-needed rather than regular reliever medication use, with frequency based on

IB
TR
symptomatic and objective improvement. Regular use of SABA for even 1–2 weeks leads to beta-receptor down-

IS
regulation, increased airway hyperresponsiveness and increased eosinophilic inflammation, with reduced

D
bronchodilator response.587,718 Ipratropium bromide, if used in the ED or hospital, may be quickly discontinued as it is

R
O
unlikely to provide ongoing benefit. Patients prescribed ICS–formoterol as their reliever should return to this on

PY
discharge if SABA was substituted in ED or hospital. O
Risk factors and triggers that contributed to the exacerbation
C
T
O

Identify factors that may have contributed to the exacerbation, and implement strategies to reduce modifiable risk
N

factors (Box 3-17, p.85). These may include irritant or allergen exposure, viral respiratory infections, inadequate long-
O
-D

term ICS treatment, problems with adherence, and/or lack of a written asthma action plan. Handwashing, masks and
social/physical distancing may reduce the risk of acquiring viral respiratory infections, including influenza.
L
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Self-management skills and written asthma action plan

ER

Review inhaler technique (Box 3-22, p.100).

AT

•
M

• Provide a written asthma action plan (Box 4-2, p.146) or review the patient’s existing plan, either at discharge or as
D

soon as possible afterwards. Patients discharged from the ED with an action plan and PEF meter have better
TE

outcomes than patients discharged without these resources.719 For patients prescribed ICS-formoterol reliever, use
H
IG

an action plan template customized for this treatment.8 Review technique with PEF meter if used.
R

• Evaluate the patient’s response as the exacerbation was developing. If it was inadequate, review the action plan
PY

and provide further written guidance to assist if asthma worsens again.719,720

O
C

• Review the patient’s use of medications before and during the exacerbation. Was ICS-containing treatment
increased promptly and by how much? Was ICS-formoterol reliever (if prescribed) increased in response to
symptoms? If OCS were indicated, were they taken; did the patient experience adverse effects? If the patient is
provided with a prescription for OCS to be on hand for subsequent exacerbations, beware of inappropriate use, as
even 4–5 lifetime courses of OCS in adults increase the risk of serious adverse effects.309
Follow up communication and appointment
• Inform the patient’s usual health care provider about their ED presentation/admission, instructions given on
discharge, and any treatment changes.
• Make a follow-up appointment within 2–7 days of discharge (1–2 days for children) to ensure that treatment is
continued. The patient should be followed to ensure that asthma symptoms return to well controlled, and that their
lung function returns to their personal best (if known).

See list of abbreviations (p.10).

4. Management of worsening asthma and exacerbations 157

C
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 TE
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Chapter 5.

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O
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O
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T
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Diagnosis and initial

N
O
-D

treatment of adults with

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features of asthma, COPD

AT
M
D
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or both
H
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O
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KEY POINTS

Asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous and overlapping conditions
• ‘Asthma’ and ‘COPD’ are umbrella labels for heterogeneous conditions characterized by chronic airway and/or
lung disease. Asthma and COPD each include several different clinical phenotypes, and are likely to have
several different underlying mechanisms, some of which may be common to both asthma and COPD.
• Symptoms of asthma and COPD may be similar, and the diagnostic criteria overlap.
Why are the labels ‘asthma’ and ‘COPD’ still important?
• There are extremely important differences in evidence-based treatment recommendations for asthma and
COPD: treatment with a long-acting beta2 agonist (LABA) and/or long-acting muscarinic antagonist (LAMA)
alone (i.e., without inhaled corticosteroids [ICS]) is recommended as initial treatment in COPD but
contraindicated in asthma due to the risk of severe exacerbations and death.

TE
• These risks are also seen in patients who have diagnoses of both asthma and COPD, making it important to

U
identify adult patients who, for safety, should not be treated with long-acting bronchodilators alone.

IB
TR
• In COPD, high-dose ICS should not be used because of the risk of pneumonia.

IS
Many patients have features of both asthma and COPD

D
R
• Distinguishing asthma from COPD can be difficult, particularly in smokers and older adults, and some patients

O
PY
may have features of both asthma and COPD.
O
• The terms ‘asthma-COPD overlap’ (ACO) or ‘asthma+COPD’ are simple descriptors for patients who have
C

features of both asthma and COPD.

T
O
N

• These terms do not refer to a single disease entity. They include patients with several clinical phenotypes that
O

are likely caused by a range of different underlying mechanisms.

-D

• More research is needed to better define these phenotypes and mechanisms, but in the meantime, safety of
L
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pharmacologic treatment is a high priority.

ER

Diagnosis
AT
M

• Diagnosis in patients with chronic respiratory symptoms involves a stepwise approach, first recognizing that the
D

patient is likely to have chronic airways disease, then syndromic categorization as characteristic asthma,
TE

characteristic COPD, with features of both or having other conditions such as bronchiectasis.
H
IG

• Lung function testing is essential for confirming persistent airflow limitation, but variable airflow obstruction can
R
PY

be detected with serial peak flow measurements and/or measurements before and after bronchodilator.
O

Initial treatment for safety and clinical efficacy

C

• For asthma: ICS are essential either alone or in combination with a long-acting bronchodilator (LABA), to
reduce the risk of severe exacerbations and death. Do not treat with LABA and/or LAMA alone, without ICS.
• For patients with features of both asthma and COPD, treat as asthma. ICS-containing therapy is important
to reduce the risk of severe exacerbations and death. Do not give LABA and/or LAMA alone without ICS.
• For COPD: Treat according to current GOLD 202359 recommendations, i.e. initial treatment with LAMA and
LABA, plus as-needed SABA; with ICS for patients with any hospitalizations, ≥2 exacerbations/year requiring
OCS, or blood eosinophils ≥300/µl.
• All patients: provide structured education especially focusing on inhaler technique and adherence; assess for,
and treat, other clinical problems, including advice about smoking cessation, immunizations, physical activity,
and management of multimorbidity.
Specialist referral for additional investigations in patients with asthma+COPD is encouraged, as they often have
worse outcomes than patients with asthma or COPD alone.

160 5. Diagnosis and initial treatment of adults with features of asthma, COPD or both
OBJECTIVES
The objectives of this section of the GINA Strategy Report are:
• To assist primary care clinicians to identify typical asthma and typical COPD and to recognize when patients have
features of both. This is particularly relevant in older patients (40 years or above)
• To provide advice about safe and effective initial treatment
• To provide guidance on indications for referral for specialist assessment.

BACKGROUND TO DIAGNOSING ASTHMA AND/OR COPD IN ADULT PATIENTS

Why are the labels ‘asthma’ and ‘COPD’ still important?
Asthma and COPD are heterogeneous conditions characterized by airway obstruction. Each of these ‘umbrella’ labels
includes several different patterns of clinical features (phenotypes) that may overlap. Each may also include different
inflammatory patterns and different underlying mechanisms, some of which may be common to both asthma and

TE
COPD.722

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The most easily recognized phenotypes of asthma and COPD such as allergic asthma in children/young adults and

TR
emphysema in older smokers are clearly distinguishable. Regulatory studies of pharmacotherapy in asthma and COPD

IS
are largely restricted to patients with very clearly defined asthma or COPD. However, in the community, the features of

D
asthma and COPD may overlap, especially in older adults.

R
O
There are extremely important differences in treatment recommendations for asthma and COPD. In particular,
PY
treatment with long-acting bronchodilators alone (i.e. without ICS) is recommended for initial treatment in COPD59 but is
O
C
contraindicated in asthma due to the risk of severe exacerbations and death.135,230,723,724 Several studies have also
T
O

shown that patients with diagnoses of both asthma and COPD are at increased risk of hospitalization or death if they are
N

treated with LABA or LABA-LAMA compared with ICS-LABA (or ICS-LABA-LAMA).725-727

O
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Challenges in clinical diagnosis of asthma and COPD

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Although asthma is characterized by variable expiratory airflow limitation, at least initially (Box 1-2, p.25), and COPD is
ER

characterized by persistent airflow limitation,59 the definitions of asthma and COPD are not mutually exclusive (Box 5-1,
AT

p.162). This means that clinical features are also important in making a diagnosis and treating appropriately.
M
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In children and young adults with chronic or recurrent respiratory symptoms, the differential diagnosis is different from
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that in older adults (see Box 1-5, p.30). Once infectious disease and nonpulmonary conditions (e.g., congenital heart
H

disease, inducible laryngeal obstruction) have been excluded, the most likely chronic airway disease in children and
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young adults is asthma.

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However, in adults with a history of long-standing asthma,728,729 persistent airflow limitation may be found 730-734
O
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Distinguishing this from COPD is problematic, especially if they are smokers or have other risk factors for COPD.735-738
On the other hand, patients with COPD may show evidence of reversible airflow obstruction when a rapid-acting
bronchodilator is administered, a feature more strongly associated with asthma. In medical records, such patients often
are assigned both diagnoses.61,739
In keeping with common usage of the term “overlap” in other contexts, e.g. for the association between COPD with sleep
disorders, and in overlap syndromes of collagen vascular disease, the descriptive term ‘asthma-COPD overlap’ is often
used. Another common descriptor is ‘asthma+COPD’.
‘Asthma-COPD overlap’ is a descriptor for patients often seen in clinical practice, who comprise a
heterogeneous group. It does not mean a single disease entity.

5. Diagnosis and initial treatment of adults with features of asthma, COPD or both 161
Prevalence and morbidity of asthma-COPD overlap
In epidemiological studies, reported prevalence rates for asthma+COPD have ranged between 9% and 55% of those
with either diagnosis, with variation by gender and age;733,740-742 the wide range reflects the different criteria that have
been used by different investigators. Concurrent doctor-diagnosed asthma and COPD has been reported in between 15
and 32% of patients with one or other diagnosis.739,743,744
There is broad agreement that patients with features of both asthma and COPD have a greater burden of symptoms,745
experience frequent exacerbations,61,731,745 have poor quality of life,61,740,745 a more rapid decline in lung function,745
higher mortality,731,739 and greater use of healthcare resources61,746 compared with patients with asthma or COPD alone.

Box 5-1. Current definitions of asthma and COPD, and clinical description of asthma-COPD overlap

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Asthma

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Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of

TR
respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in

IS
D
intensity, together with variable expiratory airflow limitation. [GINA 2023]

R
O
COPD

PY
O
Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition characterized by chronic respiratory
C

symptoms (dyspnea, cough, sputum production and/or exacerbations) due to abnormalities of the airways (bronchitis,
T
O

bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction. [GOLD 2023]59
N
O
-D

Asthma+COPD, also called asthma-COPD overlap

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‘Asthma-COPD overlap’ and ‘asthma +COPD’ are terms used to collectively describe patients who have persistent
ER

airflow limitation together with clinical features that are consistent with both asthma and COPD.
AT

This is not a definition of a single disease entity, but a descriptive term for clinical use that includes several different
M
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clinical phenotypes reflecting different underlying mechanisms.

TE

See list of abbreviations (p.10).

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ASSESSMENT AND MANAGEMENT OF PATIENTS WITH CHRONIC RESPIRATORY SYMPTOMS

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1: History and clinical assessment to establish the following:

C

• The nature and pattern of respiratory symptoms (variable and/or persistent)

• History of asthma diagnosis; childhood and/or current

• Exposure history: smoking and/or other exposures to risk factors for COPD.
The features that are most helpful in identifying and distinguishing asthma from COPD, and the features that should
prompt a patient to be treated as asthma to reduce the risk of severe exacerbations and death, are shown in Box 5-2.
Caution: Consider alternative diagnoses: Other airways diseases, such as bronchiectasis and chronic bronchitis, and
other forms of lung disease such as interstitial lung disease may present with some of the above features. The approach
to diagnosis provided here does not replace the need for a full assessment of patients presenting with respiratory
symptoms, to first exclude non-respiratory diagnoses such as heart failure.20 Physical examination may provide
supportive information.

162 5. Diagnosis and initial treatment of adults with features of asthma, COPD or both
 Box 5-2. Approach to initial treatment in patients with asthma and/or COPD

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See list of abbreviations (p.10.

5. Diagnosis and initial treatment of adults with features of asthma, COPD or both 163
2: Lung function testing is essential to confirm the following:
• The presence of persistent expiratory airflow limitation
• Variable expiratory airflow limitation.
Spirometry is preferably performed at the initial assessment. In cases of clinical urgency it may be delayed to a
subsequent visit, but confirmation of diagnosis may be more difficult once patients are started on ICS-containing therapy
(see Box 1-3, p.28). Early confirmation (or exclusion) of the presence of persistent expiratory airflow limitation may avoid
needless trials of therapy, or delays in initiating other investigations. Spirometry can confirm both persistent airflow
limitation and reversibility (Box 5-2, p.163, Box 5-3, p.164).
Measurement of peak expiratory flow (PEF), if performed repeatedly on the same meter over a period of 1–2 weeks,
may help to confirm reversible airflow limitation and the diagnosis of asthma by demonstrating excessive variability (Box
1-2, p.25). However, PEF is not as reliable as spirometry, and a normal PEF does not rule out either asthma or COPD.

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Box 5-3. Spirometric measures in asthma and COPD

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Spirometric variable Asthma COPD Asthma+COPD

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Normal FEV1/FVC Compatible with asthma. Not compatible with COPD Not compatible

R
pre- or post BD If patient is symptomatic at a

O
PY
time when lung function is
normal, consider alternative O
C
diagnosis.
T
O

Reduced post-BD FEV1/FVC Indicates airflow limitation Required for diagnosis of Required for diagnosis of
N

(< lower limit of normal, or but may improve COPD asthma+COPD

O

<0.7 (GOLD)) spontaneously or on

-D

treatment
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Post-BD FEV1 ≥80% Compatible with diagnosis of Compatible with mild Compatible with mild
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predicted asthma (good asthma persistent airflow limitation if persistent airflow limitation
AT

control or interval between post-BD FEV1/FVC is reduced if post-BD FEV1/FVC is

M

symptoms) reduced
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Post-BD FEV1 <80% Compatible with diagnosis of An indicator of severity of As for COPD and asthma
H

predicted asthma. Risk factor for airflow limitation and risk of

IG

asthma exacerbations future events (e.g., mortality

R

and COPD exacerbations)

PY
O

Post-BD increase in FEV1 Usual at some time in course Common and more likely Common and more likely
C

≥12% and 200 mL from of asthma, but may not be when FEV1 is low when FEV1 is low
baseline (reversible airflow present when well controlled
limitation). or on ICS-containing therapy
Post-BD increase in FEV1 High probability of asthma Unusual in COPD Compatible with
>12% and 400 mL from asthma+COPD
baseline (marked
reversibility)
See list of abbreviations (p.10).

164 5. Diagnosis and initial treatment of adults with features of asthma, COPD or both
3: Selecting initial treatment (See Box 5-2, p.163)
For asthma
Commence treatment as described in Chapter 3 (Box 3-4,A-D, p.59–p.63). Pharmacotherapy is based on ICS to reduce
the risk of severe exacerbations and death and to improve symptom control, with add-on treatment as required,
e.g., add-on LABA and/or LAMA. As-needed low-dose ICS-formoterol may be used as the reliever, on its own in mild
asthma or in addition to maintenance ICS-formoterol in patients with moderate-severe asthma prescribed maintenance
and reliever therapy (see Box 3-12, p.65). Inhaled therapy should be optimized to minimize the need for oral
corticosteroids (OCS).
For COPD
Commence treatment as in the current GOLD strategy report.59 Pharmacotherapy starts with symptomatic treatment
with long-acting bronchodilators (LABA and LAMA). ICS may be added as per GOLD for patients with hospitalizations in
the last year, ≥2 exacerbations/year requiring OCS, or blood eosinophils ≥300/µL, but is not used alone as monotherapy

TE
without LABA and/or LAMA. Inhaled therapy should be optimized to reduce the need for OCS. In patients with features

U
of COPD, high-dose ICS should be avoided because of the risk of pneumonia.747,748

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For patients with features of asthma and COPD

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Start treatment as for asthma (Box 3-4,A-D, p.59–p.63) until further investigations have been performed.

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O
ICS play a pivotal role in preventing morbidity and even death in patients with uncontrolled asthma symptoms, for whom

PY
even seemingly ‘mild’ symptoms (compared to those of moderate or severe COPD) might indicate significant risk of a
O
life-threatening attack.749 For patients with asthma+COPD, ICS should be used initially in a low or medium dose (see
C

Box 3-14, p.67), depending on level of symptoms and risk of adverse effects, including pneumonia.
T
O
N

Patients with features or diagnosis of both asthma and COPD will usually also require add-on treatment with LABA
O

and/or LAMA to provide adequate symptom control.

-D

Patients with any features of asthma should not be treated with LABA and/or LAMA alone, without ICS. A large
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case-control study in community patients with newly diagnosed COPD found that those who also had a diagnosis of
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asthma had a lower risk of COPD hospitalizations and death if treated with combination ICS-LABA than with LABA
AT

alone.725 In another large retrospective longitudinal population cohort study of patients aged ≥66 years, those recorded
M

as having asthma with COPD had lower morbidity and hospitalizations if they received ICS treatment; a similar benefit
D
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was seen in those with COPD plus concurrent asthma.727

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All patients with chronic airflow limitation

R
PY

Provide advice, as described in the GINA and GOLD reports, about:

O

• Treatment of modifiable risk factors including advice about smoking cessation

C

• Treatment of comorbidities
• Non-pharmacological strategies including physical activity, and, for COPD or asthma-COPD overlap, pulmonary
rehabilitation and vaccinations
• Appropriate self-management strategies
• Regular follow-up.
In a majority of patients, the initial management of asthma and COPD can be satisfactorily carried out at primary care
level. However, both the GINA and GOLD strategy reports recommend referral for further diagnostic procedures at
relevant points in patient management (see below). This may be particularly important for patients with features of both
asthma and COPD, given that this is associated with worse outcomes and greater health care utilization.

5. Diagnosis and initial treatment of adults with features of asthma, COPD or both 165
4: Referral for specialized investigations (if necessary)
Referral for expert advice and further diagnostic evaluation is advised in the following contexts:
• Patients with persistent symptoms and/or exacerbations despite treatment.
• Diagnostic uncertainty, especially if an alternative diagnosis (e.g., bronchiectasis, post-tuberculous scarring,
bronchiolitis, pulmonary fibrosis, pulmonary hypertension, cardiovascular diseases and other causes of respiratory
symptoms) needs to be investigated.
• Patients with suspected asthma or COPD in whom atypical or additional symptoms or signs (e.g., hemoptysis,
significant weight loss, night sweats, fever, signs of bronchiectasis or other structural lung disease) suggest an
additional pulmonary diagnosis. This should prompt early referral, without waiting for a trial of treatment for
asthma or COPD.
• When chronic airways disease is suspected but syndromic features of either asthma or COPD are few.
• Patients with comorbidities that may interfere with the assessment and management of their airways disease,
particularly cardiovascular disease.

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• Referral may also be appropriate for issues arising during ongoing management of asthma, COPD or asthma-

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COPD overlap, as outlined in the GINA and GOLD strategy reports.

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Box 5-4 (p.166) summarizes specialized investigations that are sometimes used to distinguish asthma and COPD.

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Box 5-4. Specialized investigations sometimes used in patients with features of asthma and COPD

Asthma PY COPD
O
C

Lung function tests

T
O
N

DLCO Normal (or slightly elevated) Often reduced

O
-D

Arterial blood gases Normal between exacerbations May be chronically abnormal between
L

exacerbations in more severe forms of COPD

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Airway hyperresponsiveness Not useful on its own in distinguishing asthma from COPD, but
AT

(AHR) higher levels of AHR favor asthma

M

Imaging
D
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High resolution CT Scan Usually normal but air trapping and Low attenuation areas denoting either air trapping
H
IG

increased bronchial wall thickness or emphysematous change can be quantitated;

R

may be observed. bronchial wall thickening and features of pulmonary

PY

hypertension may be seen.

O
C

Inflammatory biomarkers
A positive test for atopy
(specific IgE and/or skin prick asthma; not essential for diagnosis of rule out COPD
test to aeroallergens)
FeNO
Blood eosinophilia
Sputum inflammatory cell
analysis
Increases probability of allergic Conforms to background prevalence; does not
asthma
A high level (>50 ppb) in non- Usually normal
smokers is moderately associated Low in current smokers
with eosinophilic airway inflammation.
Supports diagnosis of eosinophilic May be present in COPD including during
airway inflammation exacerbations
Role in differential diagnosis is not established in large populations.

See list of abbreviations (p.10).

166 5. Diagnosis and initial treatment of adults with features of asthma, COPD or both
FUTURE RESEARCH
There is an urgent need for more research on this topic, in order to guide better recognition and safe and effective
treatment. Patients who do not have ‘classical’ features of asthma or of COPD, or who have features of both, have
generally been excluded from randomized controlled trials of most therapeutic interventions for airways disease, and
from many mechanistic studies.
Future research should include study of clinical and physiological characteristics, biomarkers, outcomes and underlying
mechanisms, among broad populations of patients with respiratory symptoms or with chronic airflow limitation. In the
meantime, the present chapter provides interim advice about diagnosis and initial treatment, from the perspective of
clinicians, particularly those in primary care and nonpulmonary specialties. Further research is needed to inform
evidence-based definitions and a more detailed classification of patients who present overlapping features of asthma
and COPD, and to encourage the development of specific interventions for clinical use.

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5. Diagnosis and initial treatment of adults with features of asthma, COPD or both 167
C
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 SECTION 2. CHILDREN 5 YEARS AND
YOUNGER

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Chapter 6.

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Diagnosis and
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management of asthma
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in children
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5 years and younger

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 6.1. DIAGNOSIS
KEY POINTS

• Recurrent wheezing occurs in a large proportion of children 5 years and younger, typically with viral upper
respiratory tract infections. It is difficult to discern when this is the initial presentation of asthma.
• Previous classifications of wheezing phenotypes (episodic wheeze and multiple-trigger wheeze; or transient
wheeze, persistent wheeze and late-onset wheeze) do not appear to identify stable phenotypes, and their clinical
usefulness is uncertain. However, emerging research suggest that more clinically relevant phenotypes will be
described and phenotype-directed therapy possible.
• A diagnosis of asthma in young children with a history of wheezing is more likely if they have:
o Wheezing or coughing that occurs with exercise, laughing or crying, or in the absence of an apparent respiratory
infection
o A history of other allergic disease (eczema or allergic rhinitis), allergen sensitization or asthma in first-degree

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relatives

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o Clinical improvement during 2–3 months of low-dose inhaled corticosteroid (ICS) treatment plus as-needed

IB
short-acting beta2 agonist (SABA) reliever, and worsening after cessation.

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ASTHMA AND WHEEZING IN YOUNG CHILDREN

R
O
Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic
PY
disease as measured by school absences, emergency department visits and hospitalizations.750 Asthma often begins in
O
C
early childhood; in up to half of people with asthma, symptoms commence during childhood.751 Onset of asthma is
T

earlier in males than females.752-754

O
N
O

No intervention has yet been shown to prevent the development of asthma or modify its long-term natural course. Atopy
-D

is present in the majority of children with asthma who are over 3 years old, and allergen-specific sensitization (and
L

particularly multiple early-life sensitizations) is one of the most important risk factors for the development of asthma.755
IA
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Viral-induced wheezing
AT
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Recurrent wheezing occurs in a large proportion of children aged 5 years or younger. It is typically associated with upper
D

respiratory tract infections (URTI), which occur in this age group around 6–8 times per year.756 Some viral infections
TE

(respiratory syncytial virus and rhinovirus) are associated with recurrent wheeze throughout childhood. Wheezing in this
H
IG

age group is a highly heterogeneous condition, and not all wheezing indicates asthma. A large proportion of wheezing
R

episodes in young children is virally induced whether the child has asthma or not. Therefore, deciding when wheezing
PY

with a respiratory infection is truly an isolated event or represents a recurrent clinical presentation of childhood asthma
O
C

may be difficult.754,757 In children aged under 1 year, bronchiolitis may present with wheeze. It is usually accompanied by
other chest signs such as crackles on auscultation.

Wheezing phenotypes
In the past, two main classifications of wheezing (called ‘wheezing phenotypes’) were proposed:
• Symptom-based classification:758 this was based on whether the child had only episodic wheeze (wheezing during
discrete time periods, often in association with URTI, with symptoms absent between episodes) or multiple-trigger
wheeze (episodic wheezing with symptoms also occurring between these episodes, e.g., during sleep or with
triggers such as activity, laughing, or crying).
• Time trend-based classification: this system was initially based on retrospective analysis of data from a cohort
study.754 It included transient wheeze (symptoms began and ended before the age of 3 years); persistent wheeze
(symptoms began before the age of 3 years and continued beyond the age of 6 years), and late-onset wheeze
(symptoms began after the age of 3 years). These general patterns have been confirmed in subsequent studies
using unsupervised statistical approaches.759,760

170 6. Diagnosis and management of asthma in children 5 years and younger

 However, prospective allocation of individual children to these phenotypes has been challenging in ‘real-life’ clinical
situations, and the clinical usefulness of these, and other, classification and asthma prediction systems remain a subject
of active investigation. For example, one study conducted in a research setting with high medication adherence found
that daily ICS treatment reduced exacerbations in pre-school children characterized as ‘sensitization with indoor pet
exposure’ or ‘multiple sensitization with eczema’, but not among those characterized as ‘minimal sensitization’ or
‘sensitization with tobacco smoke exposure’.761

CLINICAL DIAGNOSIS OF ASTHMA

It may be challenging to make a confident diagnosis of asthma in children 5 years and younger, because episodic
respiratory symptoms such as wheezing and cough are also common in children without asthma, particularly in those
aged 0–2 years,762,763 and it is not possible to routinely assess airflow limitation or bronchodilator responsiveness in this
age group. A probability-based approach, based on the pattern of symptoms during and between viral respiratory
infections,764 may be helpful for discussion with parents/caregivers (Box 6-1 & 2). This allows individual decisions to be
made about whether to give a trial of controller treatment. It is important to make decisions for each child individually, to

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avoid either over- or under-treatment.

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Box 6-1. Probability of asthma diagnosis in children 5 years and younger

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Symptoms suggestive of asthma in children 5 years and younger

As shown in Boxes 6-1, 6-2 and 6-3, an asthma diagnosis in children 5 years and younger can often be based on:
• Symptom patterns (recurrent episodes of wheeze, cough, breathlessness (typically manifested by activity
limitation), and nocturnal symptoms or awakenings)
• Presence of risk factors for development of asthma, such as family history of atopy, allergic sensitization, allergy
or asthma, or a personal history of food allergy or atopic dermatitis
• Therapeutic response to controller treatment.
• Exclusion of alternate diagnoses.

6. Diagnosis and Management of asthma in children 5 years and younger 171

 Box 6-1 is a schematic figure showing the estimated probability of an asthma diagnosis765,766 in children aged 5 years or
younger who have viral-induced cough, wheeze or heavy breathing, based on the pattern of symptoms.
Many young children wheeze with viral infections; it may be difficult to decide when a child should be given controller
treatment. The frequency and severity of wheezing episodes and the temporal pattern of symptoms (only with viral colds
or also in response to other triggers) should be taken into account. Any controller treatment should be viewed as a
treatment trial, with follow up scheduled after 2–3 months to review the response. Review is also important since the
pattern of symptoms tends to change over time in a large proportion of children.
A diagnosis of asthma in young children is therefore based largely on recurrent symptom patterns combined with a
careful clinical assessment of family history and physical findings with careful consideration of the differential diagnostic
possibilities. A positive family history of allergic disorders, or the presence of atopy or allergic sensitization provide
additional predictive support, as early allergic sensitization increases the likelihood that a wheezing child will develop
persistent asthma.755

Box 6-2. Features suggesting a diagnosis of asthma in children 5 years and younger

TE
U
IB
Feature Characteristics suggesting asthma

TR
Cough • Recurrent or persistent non-productive cough that may be worse at night

IS
or accompanied by wheezing and breathing difficulties

D
R
• Cough occurring with exercise, laughing, crying or exposure to tobacco

O
smoke, particularly in the absence of an apparent respiratory infection
PY
O
Wheezing • Recurrent wheezing, including during sleep or with triggers such as activity,
C

laughing, crying or exposure to tobacco smoke or air pollution

T
O
N

Difficult or heavy breathing or • Occurring with exercise, laughing, or crying

O

shortness of breath
-D
L

Reduced activity • Not running, playing or laughing at the same intensity as other children;
IA
ER

tires earlier during walks (wants to be carried)

AT

Past or family history • Other allergic disease (atopic dermatitis or allergic rhinitis, food allergy).
M

Asthma in first-degree relative(s)

D
TE

Therapeutic trial with low-dose ICS • Clinical improvement during 2–3 months of low-dose ICS treatment and
H

(Box 6-6, p.183) plus as-needed SABA

IG

worsening when treatment is stopped

R
PY

See list of abbreviations (p.10).

O

Wheeze
C

Wheeze is the most common and specific symptom associated with asthma in children 5 years and younger. Wheezing
occurs in several different patterns, but a wheeze that occurs recurrently, during sleep, or with triggers such as activity,
laughing, or crying, is consistent with a diagnosis of asthma. Clinician confirmation is important, as parents/caregivers
may describe any noisy breathing as ‘wheezing’.767 Some cultures do not have a word for wheeze.
Wheezing may be interpreted differently based on:
• Who observes it (e.g., parent/caregiver versus the health care provider)
• The environmental context (e.g,. high income countries versus areas with a high prevalence of parasites that
involve the lung)
• The cultural context (e.g., the relative importance of certain symptoms can differ between cultures, as can the
diagnosis and treatment of respiratory tract diseases in general).

172 6. Diagnosis and management of asthma in children 5 years and younger

 Box 6-3. Questions that can be used to elicit features suggestive of asthma

• Does your child have wheezing? Wheezing is a high-pitched noise which comes from the chest and not the throat.
Use of a video questionnaire,768 or asking a parent/caregiver to record an episode on a smartphone if available
can help to confirm the presence of wheeze and differentiate from upper airway abnormalities.
• Does your child wake up at night because of coughing, wheezing, or difficult breathing, heavy breathing, or
breathlessness?
• Does your child have to stop running, or play less hard, because of coughing, wheezing or difficult breathing,
heavy breathing, or shortness of breath?
• Does your child cough, wheeze or get difficult breathing, heavy breathing, or shortness of breath when laughing,
crying, playing with animals, or when exposed to strong smells or smoke?
In children with respiratory symptoms, additional features may help to support the diagnosis of asthma
• Has your child ever had eczema, or been diagnosed with allergy to foods?

TE
• Has anyone in your family had asthma, hay fever, food allergy, eczema, or any other disease with breathing

U
IB
problems?

TR
IS
Cough

D
R
Cough due to asthma is generally non-productive, recurrent and/or persistent, and is usually accompanied by wheezing

O
episodes and breathing difficulties. Allergic rhinitis may be associated with cough in the absence of asthma. A nocturnal
PY
cough (when the child is asleep) or a cough that occurs with exercise, laughing or crying, in the absence of an apparent
O
respiratory infection, supports a diagnosis of asthma. The common cold and other respiratory illnesses including
C
T

pertussis are also associated with coughing. Prolonged cough in infancy, and cough without cold symptoms, are
O
N

associated with later parent/caregiver-reported physician-diagnosed asthma, independent of infant wheeze.

O

Characteristics of cough in infancy may be early markers of asthma susceptibility, particularly among children with
-D

maternal asthma.769
L
IA

Breathlessness
ER
AT

Parents/caregivers may also use terms such as ‘difficult breathing’, ‘heavy breathing’, or ‘shortness of breath’.
M

Breathlessness that occurs during exercise and is recurrent increases the likelihood of the diagnosis of asthma. In
D

infants and toddlers, crying and laughing are equivalent to exercise in older children.
TE
H

Activity and social behavior

IG
R

Physical activity is an important trigger of asthma symptoms in young children. Young children with poorly controlled
PY

asthma often abstain from strenuous play or exercise to avoid symptoms, but many parents/caregivers are unaware of
O

such changes in their children’s lifestyle. Engaging in play is important for a child’s normal social and physical
C

development. For this reason, careful review of the child’s daily activities, including their willingness to walk and play, is
important when assessing a potential asthma diagnosis in a young child. Parents/caregivers may report irritability,
tiredness and mood changes in their child as the main problems when asthma is not well controlled.

TESTS TO ASSIST IN DIAGNOSIS

While no tests specifically and definitively diagnose asthma with certainty, in children 5 years and younger, the following
are useful adjuncts.

Therapeutic trial
A trial of treatment for at least 2–3 months with as-needed SABA and regular low-dose ICS may provide some guidance
about the diagnosis of asthma (Evidence D). Response should be evaluated by symptom control (daytime and night-
time), and the frequency of wheezing episodes and exacerbations. Marked clinical improvement during treatment, and

6. Diagnosis and Management of asthma in children 5 years and younger 173

 deterioration when treatment is stopped, support a diagnosis of asthma. Due to the variable nature of asthma in young
children, a therapeutic trial may need to be repeated in order to be certain of the diagnosis.

Tests for allergic sensitization

Sensitization to allergens can be assessed using either skin prick testing or allergen-specific immunoglobulin E. Allergic
sensitization is present in the majority of children with asthma once they are over 3 years of age; however, absence of
sensitization to common aeroallergens does not rule out a diagnosis of asthma. Allergic sensitization is the best
predictor for development of persistent asthma.770

Chest X-ray
Radiographs are rarely indicated; however, if there is doubt about the diagnosis of asthma in a wheezing or coughing
child, a plain chest X-ray may help to exclude structural abnormalities (e.g., congenital lobar emphysema, vascular ring)
chronic infections such as tuberculosis, an inhaled foreign body, or other diagnoses. Other imaging investigations may
be appropriate, depending on the condition being considered.

TE
U
IB
Lung function testing

TR
Due to the inability of most children 5 years and younger to perform reproducible expiratory maneuvers, lung function

IS
D
testing, bronchial provocation testing, and other physiological tests do not have a major role in the diagnosis of asthma

R
at this age. However, by 5 years of age, many children are capable of performing reproducible spirometry if coached by

O
PY
an experienced technician and with visual incentives.
O
C
Exhaled nitric oxide
T
O

Measurement of fractional concentration of exhaled nitric oxide (FeNO) is not widely available for most children in this
N
O

age group and currently remains primarily a research tool. FeNO can be measured in young children with tidal breathing,
-D

and normal reference values have been published for children aged 1–5 years.771 In pre-school children with recurrent
L

coughing and wheezing, an elevated FeNO recorded 4 weeks from any URTI predicted physician-diagnosed asthma at
IA
ER

school age,772 and increased the odds for wheezing, asthma and ICS use by school age, independent of clinical history
AT

and presence of specific IgE.773

M
D

Risk profiles
TE

A number of risk profile tools aimed at identifying which wheezing children aged 5 years and younger are at high risk of
H
IG

developing persistent asthma symptoms have been evaluated for use in clinical practice. However, these tools have
R

shown limited performance for clinical practice. Only three prediction tools have been externally validated (Asthma
PY

Predictive Index774 from Tucson, USA, Prevention and Incidence of Asthma and Mite Allergy (PIAMA) index675 from the
O
C

Netherlands, and Leicester tool775 from the UK), and a systematic review has shown that these tools have poor
predictive accuracy, with variation in sensitivity and positive predictive value.776 Larger predictive studies using more
advanced statistical methods, and with objective measurements for asthma diagnosis, are probably needed to propose a
practical tool in clinical care to predict persistent asthma in recurrent wheezers in infancy and pre-school age. The role of
these tools is to help identify children at greater risk of developing persistent asthma symptoms, not as criteria for the
diagnosis of asthma in young children. Each tool demonstrates different performance characteristics with varying criteria
used to identify risk.777

174 6. Diagnosis and management of asthma in children 5 years and younger

DIFFERENTIAL DIAGNOSIS
A definite diagnosis of asthma in this young age group is challenging but has important clinical consequences. It is
particularly important in this age group to consider and exclude alternative causes that can lead to symptoms of wheeze,
cough, and breathlessness before confirming an asthma diagnosis (Box 6-4).762

Box 6-4. Common differential diagnoses of asthma in children 5 years and younger

Condition Typical features

Recurrent viral respiratory Mainly cough, runny congested nose for <10 days; no symptoms between infections
tract infections
Gastroesophageal reflux Cough when feeding; recurrent chest infections; vomits easily especially after large
feeds; poor response to asthma medications

TE
Foreign body aspiration Episode of abrupt, severe cough and/or stridor during eating or play; recurrent chest

U
IB
infections and cough; focal lung signs

TR
IS
Pertussis Protracted paroxysms of coughing, often with stridor and vomiting

D
R
Persistent bacterial Persistent wet cough; poor response to asthma medications

O
PY
bronchitis
O
Tracheomalacia Noisy breathing when crying or eating, or during upper airway infections (noisy inspiration
C
T

if extrathoracic or expiration if intrathoracic); harsh cough; inspiratory or expiratory

O
N

retraction; symptoms often present since birth; poor response to asthma medications
O
-D

Tuberculosis Persistent noisy respirations and cough; fever unresponsive to normal antibiotics;
enlarged lymph nodes; poor response to bronchodilators or inhaled corticosteroids;
L
IA

contact with someone who has tuberculosis

ER
AT

Congenital heart disease Cardiac murmur; cyanosis when eating; failure to thrive; tachycardia; tachypnea or
M

hepatomegaly; poor response to asthma medications

D
TE

Cystic fibrosis Cough starting shortly after birth; recurrent chest infections; failure to thrive
H

(malabsorption); loose greasy bulky stools

IG
R

Primary ciliary dyskinesia Cough and recurrent chest infections; neonatal respiratory distress, chronic ear infections
PY

and persistent nasal discharge from birth; poor response to asthma medications; situs
O

inversus occurs in about 50% of children with this condition

C

Vascular ring Persistently noisy breathing; poor response to asthma medications

Bronchopulmonary Infant born prematurely; very low birth weight; needed prolonged mechanical ventilation
dysplasia or supplemental oxygen; difficulty with breathing present from birth
Immune deficiency Recurrent fever and infections (including non-respiratory); failure to thrive
See list of abbreviations (p.10).

6. Diagnosis and Management of asthma in children 5 years and younger 175

Key indications for referral of a child 5 years or younger for further diagnostic investigations or therapeutic
decisions
Any of the following features suggest an alternative diagnosis and indicate the need for further investigations:
• Failure to thrive
• Neonatal or very early onset of symptoms (especially if associated with failure to thrive)
• Vomiting associated with respiratory symptoms
• Continuous wheezing
• Failure to respond to asthma medications (inhaled ICS, oral steroids or SABA)
• No association of symptoms with typical triggers, such as viral URTI
• Focal lung or cardiovascular signs, or finger clubbing
• Hypoxemia outside context of viral illness.

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

176 6. Diagnosis and management of asthma in children 5 years and younger

 6.2. ASSESSMENT AND MANAGEMENT

KEY POINTS

• The goals of asthma management in young children are similar to those in older patients:
o To achieve good control of symptoms and maintain normal activity levels
o To minimize the risk of asthma flare-ups, impaired lung development and medication side-effects.
• Wheezing episodes in young children should be treated initially with inhaled SABA, regardless of whether the
diagnosis of asthma has been made. However, for initial episodes of wheeze in children <1 year in the setting of
infectious bronchiolitis, SABAs are generally ineffective.
• A trial of low-dose ICS treatment should be given if the symptom pattern suggests asthma, alternative diagnoses
have been excluded and respiratory symptoms are uncontrolled and/or wheezing episodes are frequent or severe.

• Response to treatment should be reviewed before deciding whether to continue it. If the response is absent or

TE
incomplete, reconsider alternative diagnoses.

U
IB
TR
• The choice of inhaler device should be based on the child’s age and capability. The preferred device is a pressurized
metered dose inhaler and spacer, with face mask for <3 years and mouthpiece for most children aged 3–5 years.

IS
D
Children should be switched from a face mask to mouthpiece as soon as they are able to demonstrate good

R
technique.

O
PY
• Review the need for asthma treatment frequently, as asthma-like symptoms remit in many young children.
O
C
T

GOALS OF ASTHMA MANAGEMENT

O
N

As with other age groups, the goals of asthma management in young children are:
O
-D

• To achieve good control of symptoms and maintain normal activity levels

L

• To minimize future risk; that is to reduce the risk of flare-ups, maintain lung function and lung development as
IA

close to normal as possible, and minimize medication side-effects.

ER
AT

Maintaining normal activity levels is particularly important in young children because engaging in play is important for
M

their normal social and physical development. It is important to also elicit the goals of the parent/caregiver, as these may
D

differ from conventional medical goals.

TE
H

The goals of asthma management are achieved through a partnership between the parent/caregiver and the health
IG

professional team, with a cycle of:

R
PY

• Assess (diagnosis, symptom control, risk factors, inhaler technique, adherence, parent preference)
O
C

• Adjust treatment (medications, non-pharmacological strategies, and treatment of modifiable risk factors)
• Review response including medication effectiveness and side-effects. This is carried out in combination with:
Education of parent/caregiver, and child (depending on the child’s age)
• Skills training for effective use of inhaler devices and encouragement of good adherence
• Monitoring of symptoms by parent/caregiver
• A written personalized asthma action plan.

ASSESSMENT OF ASTHMA

What does ‘asthma control’ mean?

Asthma control means the extent to which the manifestations of asthma are controlled, with or without treatment. 29,69 It
has two components (Box 6-5, p.178): the child’s asthma status over the previous four weeks (current symptom control),
and how asthma may affect them in the future (future risk). In young children, as in older patients, both symptom control

6. Diagnosis and management of asthma in children 5 years and younger 177

 and future risk should be monitored (Evidence D). The rationale for this is described on p.40.

Assessing asthma symptom control

Defining satisfactory symptom control in children 5 years and younger depends on information derived from family
members and carers, who may be unaware either of how often the child has experienced asthma symptoms, or that their
respiratory symptoms represent uncontrolled asthma. Few objective measures to assess symptom control have been
validated for children <4 years. The Childhood Asthma Control Test can be used for children aged 4–11 years.91 The
Test for Respiratory and Asthma Control in Kids (TRACK) is a validated questionnaire for parent/caregiver completion
for preschool-aged children with symptoms consistent with asthma; it includes both symptom control and courses of
systemic corticosteroids in the previous year.95 However, children with no interval symptoms can still be at risk of
exacerbations.
Box 6-5 shows a working schema for assessing asthma control in children ≤5 years, based on current expert opinion. It
incorporates assessment of symptoms; the child’s level of activity and their need for reliever/rescue treatment; and

TE
assessment of risk factors for adverse outcomes (Evidence D).

U
IB
Box 6-5. GINA assessment of asthma control in children 5 years and younger

TR
IS
A. Symptom control Level of asthma symptom control

D
R
Well Partly

O
In the past 4 weeks, has the child had: Uncontrolled
controlled controlled
Daytime asthma symptoms for more than a few minutes, Yes No PY
O
C
more than once a week?
T
O

Any activity limitation due to asthma? (Runs/plays less Yes No

None 1–2 3–4
N

than other children, tires easily during walks/playing?)

O

of these of these of these

-D

SABA reliever medication needed* more than once a week?Yes No

L

Any night waking or night coughing due to asthma? Yes No

IA
ER

B. Future risk for poor asthma outcomes

AT
M

Risk factors for asthma exacerbations within the next few months
D
TE

• Uncontrolled asthma symptoms

H

• One or more severe exacerbations (ED attendance, hospitalization, or course of OCS) in previous year
IG

The start of the child’s usual ‘flare-up’ season (especially if autumn/fall)

R

•
PY

• Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g., house dust mite, cockroach,
O

pets, mold), especially in combination with viral infection778

C

• Major psychological or socio-economic problems for child or family

• Poor adherence with ICS medication, or incorrect inhaler technique
• Outdoor pollution (NO2 and particles)111
Risk factors for persistent airflow limitation
• Severe asthma with several hospitalizations
• History of bronchiolitis
Risk factors for medication side-effects
• Systemic: Frequent courses of OCS, high-dose and/or potent ICS (see Box 6-7, p.184
• Local: moderate-to high-dose or potent ICS; incorrect inhaler technique; failure to protect skin or eyes when using
ICS by nebulizer or spacer with face mask

See list of abbreviations (p.10). * Excludes reliever taken before exercise. Before stepping up treatment, ensure that the child’s symptoms are due to
asthma, and that the child has good inhaler technique and good adherence to existing treatment.

178 6. Diagnosis and management of asthma in children 5 years and younger

Assessing future risk of adverse outcomes
The relationship between symptom control and future risk of adverse outcomes, such as exacerbations (Box 6-5, p.178),
has not been sufficiently studied in young children. Although exacerbations may occur in children after months of
apparently good symptom control, the risk is greater if current symptom control is poor. Preschool children at high risk of
asthma (based on modified API) who were treated with daily low-dose ICS experienced fewer days with asthma
symptoms and a reduced risk of exacerbations than those receiving placebo.779
The future risk of harm due to excessive doses of inhaled or systemic corticosteroids must also be avoided. This can be
minimized by ensuring that the prescribed treatment is appropriate and reduced to the lowest dose that maintains
satisfactory symptom control and minimizes exacerbations. The child’s height should be measured and recorded at least
yearly, as growth velocity may be lower in the first 1–2 years of ICS treatment,132 and poorly controlled asthma can affect
growth.131 The minimum effective dose of ICS to maintain good asthma control should be used. If decreased growth
velocity is seen, other factors should be considered, including poorly controlled asthma, frequent use of oral
corticosteroids (OCS), and poor nutrition, and referral should be considered.

TE
If ICS is delivered through a face-mask or nebulizer, the skin on the nose and around the mouth should be cleaned

U
shortly after inhalation in order to avoid local side-effects such as steroid rash (reddening and atrophy).

IB
TR
IS
MEDICATIONS FOR SYMPTOM CONTROL AND RISK REDUCTION

D
R
Choosing medications for children 5 years and younger

O
PY
Good control of asthma can be achieved in the overwhelming majority of young children with a pharmacological
O
intervention strategy.780 This should be developed in a partnership between the family/carer and the health care provider.
C
T

As with older children and adults, medications comprise only one component of asthma management in young children;
O
N

other key components include education, skills training for inhaler devices and adherence, non-pharmacological
O

strategies including environmental control where appropriate, regular monitoring, and clinical review (see later sections in
-D

this chapter).
L
IA

When recommending treatment for a young child, both general and individual questions apply (Box 3-3, p.52).
ER

• What is the ‘preferred’ medication option at each treatment step to control asthma symptoms and minimize future
AT

risk? These decisions are based on data for efficacy, effectiveness and safety from clinical trials, and on
M

observational data. Studies suggest that consideration of factors such as allergic sensitization and/or peripheral
D
TE

blood count may help to better identify which children are more likely to have a short-term response to ICS.781
H

However, further studies are needed to assess the applicability of these findings in a wider range of settings,
IG
R

particularly in areas where blood eosinophilia may reflect helminth infection rather than asthma or atopy.
PY

• How does this individual child differ from other children with asthma, in terms of:
O
C

o Response to previous treatment

o Preferences of the parent/caregiver (goals, beliefs and concerns about medications)
o Practical issues (cost, inhaler technique and adherence)?
The following treatment recommendations for children of 5 years of age or younger are based on the available evidence
and on expert opinion. Although the evidence is expanding it is still rather limited as most clinical trials in this age group
have not characterized participants with respect to their symptom pattern, and different studies have used different
outcomes and different definitions of exacerbations.
A stepwise treatment approach is recommended (Box 6-6, p.183), based on symptom patterns, risk of exacerbations and
side-effects, and response to initial treatment. Generally, treatment includes the daily, long-term use of low-dose ICS
treatment to keep asthma well controlled, and reliever medications for as-needed symptom relief. The choice of inhaler
device is also an important consideration (Box 6-8, p.185).

6. Diagnosis and management of asthma in children 5 years and younger 179

Which children should be prescribed regular controller treatment?
Intermittent or episodic wheezing of any severity may represent an isolated viral-induced wheezing episode, an episode
of seasonal or allergen-induced asthma, or unrecognized uncontrolled asthma. The initial treatment of wheezing is
identical for all of these – a SABA every 4–6 hours as needed until symptoms disappear, usually within 1 to 7 days.
Further treatment of the acute wheezing episodes themselves is described below (see Acute asthma exacerbations in
children 5 years and younger, p.187). However, uncertainty surrounds the addition of other medications in these
children, especially when the nature of the episode is unclear. In general, the following principles apply.
• If the history and symptom pattern suggest a diagnosis of asthma (Box 6-2, p.172; Box 6-3, p.173) and respiratory
symptoms are uncontrolled (Box 6-5, p.178) and/or wheezing episodes are frequent (e.g., three or more episodes
in a season), regular controller treatment (usually maintenance low-dose ICS) should be initiated (Step 2, Box 6-6,
p.183) and the response evaluated (Evidence D). Regular ICS treatment may also be indicated in a child with less
frequent, but more severe episodes of viral- induced wheeze (Evidence D).
• If the diagnosis of asthma is in doubt, and inhaled SABA therapy or courses of antibiotics need to be repeated
frequently, e.g., more than every 6–8 weeks, a trial of regular ICS treatment should be considered to confirm

TE
whether the symptoms are due to asthma (Evidence D). Referral for specialist opinion should also be considered

U
IB
at this stage.

TR
IS
It is important to discuss the decision to prescribe controller treatment and the choice of treatment with the child’s

D
parents or caregivers. They should be aware of both the relative benefits and risks of the treatments, and the importance

R
of maintaining normal activity levels for their child’s normal physical and social development. Although effects of ICS on

O
PY
growth velocity are seen in pre-pubertal children in the first 1–2 years of treatment, this is not progressive or cumulative,
O
and the one study that examined long-term outcomes showed a difference of only 0.7% in adult height.132,782 Poorly
C
controlled asthma itself adversely affects adult height.131
T
O
N

Treatment steps to control asthma symptoms and minimize future risk for children 5 years and younger
O
-D

Asthma treatment in young children follows a stepwise approach (Box 6-6), with medication adjusted up or down to
L

achieve good symptom control and minimize future risk of exacerbations and medication side-effects. The need for
IA
ER

controller treatment should be re-assessed regularly.

AT

Before considering a step-up of controller treatment

M
D

If symptom control is poor and/or exacerbations persist despite 3 months of adequate controller therapy, check the
TE

following before any step up in treatment is considered.

H
IG

• Confirm that the symptoms are due to asthma rather than a concomitant or alternative condition (Box 6-4, p.176).
R

Refer for expert assessment if the diagnosis is in doubt.

PY

• Check and correct inhaler technique.

O
C

• Confirm good adherence with the prescribed dose.

• Consider trial of one of the other treatment options for that step, as many children may respond to one of the
options.
• Enquire about risk factors such as allergen or tobacco smoke exposure (Box 6-5, p.178).

180 6. Diagnosis and management of asthma in children 5 years and younger

ASTHMA TREATMENT STEPS FOR CHILDREN AGED 5 YEARS AND YOUNGER

STEP 1: As-needed inhaled short-acting beta2-agonist (SABA)

Preferred option: as-needed inhaled short-acting beta2-agonist (SABA)

All children who experience wheezing episodes should be provided with inhaled SABA for relief of symptoms (Evidence
D), although it is not effective in all children. See Box 6-8 (p.185) for choice of inhaler device. Use of SABA for the relief
of symptoms on average more than twice a week over a 1-month period indicates the need for a trial of low-dose ICS
treatment. Initial episodes of wheeze in children <1 year often occur in the setting of infectious bronchiolitis, and this
should be managed according to local bronchiolitis guidelines. SABAs are generally ineffective for bronchiolitis.783
Other options
Oral bronchodilator therapy is not recommended due to its slower onset of action and higher rate of side-effects,

TE
compared with inhaled SABA (Evidence D).

U
IB
For children with intermittent viral-induced wheeze and no interval symptoms, particularly those with underlying atopy

TR
(positive for modified API) in whom inhaled SABA medication is not sufficient, intermittent high-dose ICS may be

IS
considered649,784,785 (see Management of worsening asthma and exacerbations, p.187), but because of the risk of side-

D
effects, this should only be considered if the physician is confident that the treatment will be used appropriately.

R
O
PY
STEP 2: Initial controller treatment plus as-needed SABA O
C

Preferred option: regular daily low-dose ICS plus as-needed SABA

T
O
N

Regular daily, low-dose ICS (Box 6-7, p.184) is recommended as the preferred initial treatment to control asthma in
O

children 5 years and younger (Evidence A).779,786-788 This initial treatment should be given for at least 3 months to
-D

establish its effectiveness in achieving good asthma control.

L
IA
ER

Other options
AT

In young children with persistent asthma, regular treatment with a leukotriene receptor antagonist (LTRA) modestly
M

reduces symptoms and need for oral corticosteroids compared with placebo.789 However, for young children with
D

recurrent viral- induced wheezing, a review concluded that neither regular nor intermittent LTRA reduces OCS-requiring
TE

exacerbations (Evidence A).790 A further systematic review found that in preschool children with asthma or recurrent
H
IG

wheezing, daily ICS was more effective in improving symptom control and reducing exacerbations than regular LTRA
R

monotherapy.791 Parents/caregivers should be counselled about the potential adverse effects of montelukast on sleep
PY

and behavior, and health professionals should consider the benefits and risks of side effects before prescribing; the FDA
O
C

has required a boxed warning about these problems.236

For preschool children with asthma characterized by frequent viral-induced wheezing and interval asthma symptoms, as-
needed (prn)792 or episodic ICS793 may be considered, but a trial of regular daily low-dose ICS should be undertaken
first. The effect on exacerbation risk seems similar for regular daily low-dose and episodic high-dose ICS.788 See also
Initial home management of asthma exacerbations, p.188.
If good asthma control is not achieved with a given therapy, trials of the alternative Step 2 therapies are recommended
prior to moving to Step 3.781

6. Diagnosis and management of asthma in children 5 years and younger 181

 STEP 3: Additional controller treatment, plus as-needed SABA and consider specialist referral

If 3 months of initial therapy with a low-dose ICS fails to control symptoms, or if exacerbations continue to occur, check
the following before any step up in treatment is considered.
• Confirm that the symptoms are due to asthma rather than a concomitant or alternative condition (Box 6-4,
p.176).
• Check and correct inhaler technique. Consider alternative delivery systems if indicated.
• Confirm good adherence with the prescribed dose.
• Enquire about risk factors, such as exposure to allergens or tobacco smoke (Box 6-5, p.178).
Preferred option: medium-dose ICS (double the ‘low’ daily dose)
Doubling the initial low dose of ICS may be the best option (Evidence C). Assess response after 3 months. The child
should be referred for expert assessment if symptom control remains poor and/or flare-ups persist, or if side-effects of
treatment are observed or suspected.

TE
U
Other options

IB
TR
Addition of a LTRA to low-dose ICS may be considered, based on data from older children (Evidence D). The relative

IS
cost of different treatment options in some countries may be relevant to controller choices for children. See note above

D
about the FDA warning for montelukast. 236

R
O
Not recommended
PY
O
There are insufficient data about the efficacy and safety of ICS-LABA in children <4 years old to recommend their use. A
C

short-term (8 week) placebo-controlled study did not show any significant difference in symptoms between combination
T
O

fluticasone propionate-salmeterol versus fluticasone propionate alone; no additional safety signals were noted in the
N

group receiving LABA.794

O
-D
L

STEP 4: Continue controller treatment and refer for expert assessment

IA
ER

Preferred option: refer the child for expert advice and further investigation (Evidence D).
AT
M

If doubling the initial dose of ICS fails to achieve and maintain good asthma control, carefully reassess inhaler technique
D

and medication adherence as these are common problems in this age group. In addition, reassess and address control
TE

of environmental factors where relevant, and reconsider the asthma diagnosis.

H
IG

Other options
R
PY

The best treatment for this population has not been established. If the diagnosis of asthma has been confirmed, options
O

to consider, with specialist advice, are:

C

• Further increase the dose of ICS for a few weeks until the control of the child’s asthma improves (Evidence D).
Monitor for side-effects.
• Add LTRA (data based on studies in older children, Evidence D). Benefits, and risks of side effects, should be
considered, as described previously. 236
• Add long-acting beta agonist (LABA) in combination with ICS; data based on studies in children ≥4 years of age
• Add a low dose of oral corticosteroid (for a few weeks only) until asthma control improves (Evidence D); monitor
for side-effects.
• Add intermittent high-dose ICS at onset of respiratory illnesses to the regular daily ICS if exacerbations are the
main problem (Evidence D).
The need for additional controller treatment should be re-evaluated at each visit and maintained for as short a period as
possible, taking into account potential risks and benefits. Treatment goals and their feasibility should be reconsidered
and discussed with the child’s family/carer.

182 6. Diagnosis and management of asthma in children 5 years and younger

Box 6-6. Personalized management of asthma in children 5 years and younger

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10). For ICS doses in children, see Box 6-7, p.184

t
 Box 6-7. Low daily doses of inhaled corticosteroids for children 5 years and younger

This is not a table of equivalence, but instead, suggestions for ‘low’ total daily doses for the ICS treatment
recommendations for children aged 5 years and younger in Box 6-6 (p.183), based on available studies and product
information. Data on comparative potency are not readily available, particularly for children, and this table does NOT
imply potency equivalence. The doses listed here are the lowest approved doses for which safety and effectiveness
have been adequately studied in this age group.
Low-dose ICS provides most of the clinical benefit for most children with asthma. Higher doses are associated with an
increased risk of local and systemic side-effects, which must be balanced against potential benefits.
Low total daily dose (mcg)
Inhaled corticosteroid
(age-group with adequate safety and effectiveness data)
BDP (pMDI, standard particle, HFA) 100 (ages 5 years and older)
BDP (pMDI, extrafine particle, HFA) 50 (ages 5 years and older)

TE
Budesonide nebulized 500 (ages 1 year and older)

U
IB
Fluticasone propionate (pMDI, standard particle, HFA) 50 (ages 4 years and older)

TR
IS
Fluticasone furoate (DPI) Not sufficiently studied in children 5 years and younger)

D
Mometasone furoate (pMDI, standard particle, HFA) 100 (ages 5 years and older)

R
O
Ciclesonide (pMDI, extrafine particle, HFA) Not sufficiently studied in children 5 years and younger
PY
O
BDP : beclometasone dipropionate. For other abbreviations see p.10. In children, pMDI should always be used with a spacer
C
T
O

REVIEWING RESPONSE AND ADJUSTING TREATMENT

N
O

Assessment at every visit should include asthma symptom control and risk factors (Box 6-5, p.178), and side-effects.
-D

The child’s height should be measured every year, or more often. Asthma-like symptoms remit in a substantial proportion
L

of children of 5 years or younger,795-797 so the need for continued controller treatment should be regularly assessed
IA
ER

(e.g,. every 3–6 months) (Evidence D). If therapy is stepped-down or discontinued, schedule a follow-up visit 3–6 weeks
AT

later to check whether symptoms have recurred, as therapy may need to be stepped-up or reinstituted (Evidence D).
M

Marked seasonal variations may be seen in symptoms and exacerbations in this age-group. For children with seasonal
D
TE

symptoms whose daily long-term controller treatment is to be discontinued (e.g., 4 weeks after their season ends), the
H

parent/caregiver should be provided with a written asthma action plan detailing specific signs of worsening asthma, the
IG

medications that should be initiated to treat it, and when and how to contact medical care.
R
PY
O

CHOICE OF INHALER DEVICE

C

Inhaled therapy constitutes the cornerstone of asthma treatment in children 5 years and younger. General information
about inhaler devices, and the issues that should be considered, are found in Chapter 3.3 (p.98) and in Box 3-21 (p.99).
These include, first, choosing the right medication(s) for the child to control symptoms, allow normal activity, and reduce
the risk of severe exacerbations; considering which delivery device is available; whether they can use it correctly after
training; and, if more than one type of inhaler device is available, their relative environmental impact.
For children aged 5 years and younger, a pressurized metered-dose inhaler (pMDI) with a valved spacer (with or without
a face mask, depending on the child’s age) is the preferred delivery system798 (Box 6-8, p.185) (Evidence A). This
recommendation is based on studies with beta2-agonists. The spacer device should have documented efficacy in young
children. The dose delivered may vary considerably between spacers, so consider this if changing from one spacer to
another.
The only possible inhalation technique in young children is tidal breathing. The optimal number of breaths required to
empty the spacer depends on the child’s tidal volume, and the dead space and volume of the spacer. Generally, 5–10
breaths will be sufficient per actuation. The way a spacer is used can markedly affect the amount of drug delivered:

184 6. Diagnosis and management of asthma in children 5 years and younger

 • Spacer size may affect the amount of drug available for inhalation in a complex way depending on the drug
prescribed and the pMDI used. Young children can use spacers of all sizes, but theoretically a lower volume
spacer (<350 mL) is advantageous in very young children.
• A single pMDI actuation should be delivered at a time, with the inhaler shaken in between. Multiple actuations into
the spacer before inhalation may markedly reduce the amount of drug inhaled.
• Delay between actuating the pMDI into the spacer and inhalation may reduce the amount of drug available. This
varies between spacers, but to maximize drug delivery, inhalation should start as soon as possible after actuation.
If a health care provider or a carer is giving the medication to the child, they should actuate the pMDI only when
the child is ready and the spacer is in the child’s mouth.
• If a face mask is used it must be fitted tightly around the child’s mouth and nose, to avoid loss of drug.
• Ensure that the valve is moving while the child is breathing through the spacer.
• Static charge may accumulate on some plastic spacers, attracting drug particles and reducing lung delivery. This
charge can be reduced by washing the spacer with detergent (without rinsing) and allowing it to air dry, but it may

TE
re-accumulate over time. Spacers made of anti-static materials or metals are less subject to this problem. If a

U
IB
patient or health care provider carries a new plastic spacer for emergency use, it should be regularly washed with

TR
detergent (e.g., monthly) to reduce static charge.

IS
• Nebulizers, the only viable alternative delivery systems in children, are reserved for the minority of children who

D
R
cannot be taught effective use of a spacer device. If a nebulizer is used for delivery of ICS, it should be used with

O
a mouthpiece to avoid the medication reaching the eyes. If a nebulizer is used, follow local infection control
procedures.
PY
O
C
T
O

Box 6-8. Choosing an inhaler device for children 5 years and younger
N
O

Age Preferred device Alternate device

-D
L

0–3 years Pressurized metered dose inhaler plus Nebulizer with face mask
IA
ER

dedicated spacer with face mask

AT

4–5 years Pressurized metered dose inhaler plus Pressurized metered dose inhaler plus dedicated spacer
M

dedicated spacer with mouthpiece with face mask or nebulizer with mouthpiece or face mask
D

See list of abbreviations (p.10).

TE
H
IG
R
PY
O
C

6. Diagnosis and management of asthma in children 5 years and younger 185

ASTHMA SELF-MANAGEMENT EDUCATION FOR CARERS OF YOUNG CHILDREN
Asthma self-management education should be provided to family members and carers of wheezy children 5 years and
younger when wheeze is suspected to be caused by asthma. An educational program should contain:
• A basic explanation about asthma and the factors that influence it
• Training about correct inhalation technique
• Information on the importance of the child’s adherence to the prescribed medication regimen
• A written asthma action plan.
Crucial to a successful asthma education program are a partnership between patient/carer and health care providers,
with a high level of agreement regarding the goals of treatment for the child, and intensive follow-up (Evidence D).30

Written asthma action plans

Asthma action plans should be provided for the family/carers of all children with asthma, including those aged 5 years
and younger (Evidence D). Action plans, developed through collaboration between an asthma educator, the health care

TE
provider and the family, have been shown to be of value in older children,799 although they have not been extensively

U
IB
studied in children of 5 years and younger. A written asthma action plan includes:

TR
• A description of how the parent or caregiver can recognize when symptom control is deteriorating

IS
D
• The medications to administer

R
• When and how to obtain medical care, including telephone numbers of services available for emergencies

O
PY
(e.g., doctors’ offices, emergency departments and hospitals, ambulance services and emergency pharmacies).
Details of treatments that can be initiated at home are provided in the following section, Part C: Management of
O
C
worsening asthma and exacerbations in children 5 years and younger, p.187.
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

186 6. Diagnosis and management of asthma in children 5 years and younger

 6.3. MANAGEMENT OF WORSENING ASTHMA AND EXACERBATIONS IN CHILDREN 5 YEARS
AND YOUNGER

KEY POINTS

Symptoms of exacerbation in young children

• Early symptoms of exacerbations in young children may include increased symptoms; increased coughing,
especially at night; lethargy or reduced exercise tolerance; impaired daily activities including feeding; and a
poor response to reliever medication.
Home management in a written asthma action plan
• Give a written asthma action plan to parents/caregivers of young children with asthma so they can recognize
an impending severe attack, start treatment, and identify when urgent hospital treatment is required.
• Initial treatment at home is with inhaled short-acting beta2-agonist (SABA), with review after 1 hour or earlier.

TE
• Parents/caregivers should seek urgent medical care if the child is acutely distressed, lethargic, fails to respond

U
to initial bronchodilator therapy, or is worsening, especially in children <1 year of age.

IB
TR
• Medical attention should be sought on the same day if inhaled SABA is needed more often than 3-hourly or for

IS
more than 24 hours.

D
R
• There is no compelling evidence to support parent/caregiver-initiated oral corticosteroids.

O
Management of exacerbations in primary care or acute care facility
PY
O
• Assess severity of the exacerbation while initiating treatment with SABA (2–6 puffs every 20 minutes for first
C
hour) and oxygen (to maintain saturation 94–98%).
T
O

• Recommend immediate transfer to hospital if there is no response to inhaled SABA within 1–2 hours; if the
N
O

child is unable to speak or drink, has a respiratory rate >40/minute or is cyanosed, if resources are lacking in
-D

the home, or if oxygen saturation is <92% on room air.

L
IA

• Consider oral prednisone/prednisolone 1–2 mg/kg/day for children attending an Emergency Department (ED)
ER

or admitted to hospital, up to a maximum of 20 mg/day for children aged 0–2 years, and 30 mg/day for
AT

children aged 3–5 years, for up to 5 days; or dexamethasone 0.6 mg/kg/day for 2 days. If there is failure of
M

resolution, or relapse of symptoms with dexamethasone, consideration should be given to switching to

D

prednisolone.
TE
H

Arrange early follow-up after an exacerbation

IG

Children who have experienced an asthma exacerbation are at risk of further exacerbations. Arrange follow-up
R

•
PY

within 1–2 days of an exacerbation and again 1–2 months later to plan ongoing asthma management.
O
C

DIAGNOSIS OF EXACERBATIONS
A flare-up or exacerbation of asthma in children 5 years and younger is defined as an acute or sub-acute deterioration in
symptom control that is sufficient to cause distress or risk to health, and necessitates a visit to a health care provider or
requires treatment with systemic corticosteroids. In pediatric literature, the term ‘episode’ is commonly used, but
understanding of this term by parents/caregivers is not known
Early symptoms of an exacerbation may include any of the following:
• Onset of symptoms of respiratory tract infection
• An acute or sub-acute increase in wheeze and shortness of breath
• An increase in coughing, especially while the child is asleep
• Lethargy or reduced exercise tolerance
• Impairment of daily activities, including feeding
• A poor response to reliever medication.

6. Diagnosis and management of asthma in children 5 years and younger 187

 In a study of children aged 2–5 years, the combination of increased daytime cough, daytime wheeze, and night-time
beta2-agonist use was a strong predictor at a group level of an imminent exacerbation (1 day later). This combination
predicted around 70% of exacerbations, with a low false positive rate of 14%. In contrast, no individual symptom was
predictive of an imminent asthma exacerbation.800
Upper respiratory symptoms frequently precede the onset of an asthma exacerbation, indicating the important role of
viral URTI in precipitating exacerbations in many, although not all, children with asthma. In a randomized controlled trial
of acetaminophen versus ibuprofen, given for pain or fever in children with mild persistent asthma, there was no
evidence of a difference in the subsequent risk of flare-ups or poor symptom control.781

INITIAL HOME MANAGEMENT OF ASTHMA EXACERBATIONS

Initial management includes an action plan to enable the child’s family members and carers to recognize worsening
asthma and initiate treatment, recognize when it is severe, identify when urgent hospital treatment is necessary, and
provide recommendations for follow up (Evidence D). The action plan should include specific information about

TE
medications and dosages and when and how to access medical care.

U
IB
Need for urgent medical attention

TR
IS
Parents/caregivers should be advised to seek medical attention immediately if:

D
• The child is acutely distressed

R
O
• The child’s symptoms are not relieved promptly by inhaled bronchodilator

PY
• The period of relief after doses of SABA becomes progressively shorter
O
• A child younger than 1 year requires repeated inhaled SABA over several hours.
C
T
O

Initial treatment at home

N
O
-D

Inhaled SABA via a mask or spacer, and review response

L

The parent/caregiver should initiate treatment with two puffs of inhaled SABA (200 mcg salbutamol [albuterol] or
IA
ER

equivalent), given one puff at a time via a spacer device with or without a facemask (Evidence D). This may be repeated
a further two times at 20-minute intervals, if needed. The child should be observed by the family/carer and, if improving,
AT

maintained in a restful and reassuring atmosphere for an hour or more. Medical attention should be sought urgently if
M
D

any of the features listed above apply; or on the same day if more than 6 puffs of inhaled SABA are required for
TE

symptom relief within the first 2 hours, or if the child has not recovered after 24 hours.
H
IG

Family/carer-initiated corticosteroids
R
PY

Although practiced in some parts of the world, the evidence to support the initiation of oral corticosteroid (OCS)
O

treatment by family/carers in the home management of asthma exacerbations in children is weak.801-805 Preemptive
C

episodic high-dose nebulized ICS may reduce exacerbations in children with intermittent viral triggered wheezing.788
However, because of the high potential for side-effects, especially if the treatment is continued inappropriately or is
given frequently, family-administered high-dose ICS should be considered only where the health care provider is
confident that the medications will be used appropriately, and the child is closely monitored for side-effects (see p.191).
Leukotriene receptor antagonists
In children aged 2–5 years with intermittent viral wheezing, one study found that a short course of an oral LTRA (for 7–
20 days, commenced at the start of an URTI or the first sign of asthma symptoms) reduced symptoms, health care
utilization and time off work for the carer.806 In contrast another study found no significant effect with LTRA vs placebo
on episode-free days (primary outcome), OCS use, health care utilization, quality of life or hospitalization in children with
or without a positive Asthma Predictive Index (API). However, activity limitation and a symptom trouble score were
significantly improved, particularly in children with a positive API.807 Parents/caregivers should be counseled about the
FDA warning about risk of adverse effects on sleep and behavior with montelukast.236

188 6. Diagnosis and management of asthma in children 5 years and younger

 Box 6-9. Management of acute asthma or wheezing in children 5 years and younger

TE
U
IB
TR
IS
D
R
O
PY
O
C
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C

See list of abbreviations (p.10).

6. Diagnosis and management of asthma in children 5 years and younger 189

PRIMARY CARE OR HOSPITAL MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS IN CHILDREN 5 YEARS
OR YOUNGER

Assessment of exacerbation severity

Conduct a brief history and examination concurrently with the initiation of therapy (Box 6-9, p.189). The presence of any
of the features of a severe exacerbation listed in Box 6-10 are an indication of the need for urgent treatment and
immediate transfer to hospital (Evidence D). Oxygen saturation from pulse oximetry of <92% on presentation (before
oxygen or bronchodilator treatment) is associated with high morbidity and likely need for hospitalization; saturation of
92–95% is also associated with higher risk.672 The FDA has issued a caution about potential overestimation of oxygen
saturation by pulse oximetry in people with dark skin color.654 Agitation, drowsiness and confusion are features of
cerebral hypoxemia. A quiet chest on auscultation indicates minimal ventilation, insufficient to produce a wheeze.
Several clinical scoring systems such as PRAM (Preschool Respiratory Assessment Measure) and PASS (Pediatric
Asthma Severity Score) have been developed for assessing the severity of acute asthma exacerbations in children.808

TE
U
Box 6-10. Initial assessment of acute asthma exacerbations in children 5 years and younger

IB
TR
Symptoms Mild Severe*

IS
D
Altered consciousness No Agitated, confused or drowsy

R
O
Oximetry on presentation (SaO2)** >95% <92%
PY
O
Speech† Sentences Words
C
T
O

Pulse rate <100 beats/minute >180 beats/minute (0–3 years)

N
O

>150 beats/minute (4–5 years)

-D

Respiratory rate ≤40/minute >40/minute

L
IA
ER

Central cyanosis Absent Likely to be present

AT

Wheeze intensity Variable Chest may be quiet

M
D

See list of abbreviations (p.10). *Any of these features indicates a severe asthma exacerbation. **Oximetry before treatment with oxygen or
TE

bronchodilator. Note FDA caution about potential overestimation of oxygen saturation with pulse oximetry in people with dark skin color.654 †
H

The developmental stage and usual capability of the child must be taken into account.
IG
R
PY

Indications for immediate transfer to hospital

O
C

Children with features of a severe exacerbation that fail to resolve within 1–2 hours despite repeated dosing with inhaled
SABA must be referred to hospital for observation and further treatment (Evidence D). Other indications are respiratory
arrest or impending arrest; lack of supervision in the home or doctor’s office; and recurrence of signs of a severe
exacerbation within 48 hours (particularly if treatment with OCS has already been given). In addition, early medical
attention should be sought for children with a history of severe life-threatening exacerbations, and those aged less than
2 years, as the risk of dehydration and respiratory fatigue is increased (Box 6-12, p.191).

190 6. Diagnosis and management of asthma in children 5 years and younger

Emergency treatment and initial pharmacotherapy
Oxygen
Treat hypoxemia urgently with oxygen by face mask to achieve and maintain percutaneous oxygen saturation 94–98%
(Evidence A). Note the FDA caution above about potential overestimation of oxygen saturation in people with dark skin
color. To avoid hypoxemia during changes in treatment, children who are acutely distressed should be treated
immediately with oxygen and SABA (2.5 mg of salbutamol or equivalent diluted in 3 mL of sterile normal saline)
delivered by an oxygen-driven nebulizer (if available). This treatment should not be delayed, and may be given before
the full assessment is completed. Transient hypoxemia due to ventilation/perfusion mismatch may occur during
treatment with SABAs.

Box 6-11. Indications for immediate transfer to hospital for children 5 years and younger

Immediate transfer to hospital is indicated if a child ≤5 years with asthma has ANY of the following:

TE
• At initial or subsequent assessment

U
o Child is unable to speak or drink

IB
TR
o Cyanosis

IS
o Respiratory rate >40 per minute

D
R
o Oxygen saturation <92% when breathing room air

O
o Silent chest on auscultation
PY
O
• Lack of response to initial bronchodilator treatment
C

Lack of response to 6 puffs of inhaled salbutamol [albuterol] (2 separate puffs, repeated 3 times) over 1–2 hours
T

o
O
N

o Persisting tachypnea* despite three administrations of inhaled SABA, even if the child shows other clinical signs
O

of improvement
-D

• Social environment that limits delivery of acute treatment, or parent/caregiver unable to manage acute asthma at
L
IA

home
ER

During transfer to hospital, continue to give inhaled SABA, oxygen (if available) to maintain saturation 94–98%, and
AT

give systemic corticosteroids (see Box 6-9, p.189)

M
D
TE

See list of abbreviations (p.10). *Normal respiratory rates: <60 breaths/minute in children 0–2 months; <50 breaths/minute in children 2–12 months;
<40 breaths/minute in children 1–5 years.
H
IG
R
PY

Inhaled bronchodilator therapy

O

The initial dose of inhaled SABA may be given by a pMDI with spacer and mask or mouthpiece or an air-driven
C

nebulizer; or, if oxygen saturation is low, by an oxygen-driven nebulizer (as described above). For most children, pMDI
plus spacer is favored as it is more efficient than a nebulizer for bronchodilator delivery809 (Evidence A), and nebulizers
can spread infectious particles. The initial dose of SABA is two puffs of salbutamol (100 mcg per puff) or equivalent,
except in acute, severe asthma when six puffs should be given. When a nebulizer is used, a dose of 2.5 mg salbutamol
solution is recommended, and infection control procedures should be followed. The frequency of dosing depends on the
response observed over 1–2 hours (see below).
For children with moderate-severe exacerbations and a poor response to initial SABA, nebulized ipratropium bromide
may be added every 20 minutes for 1 hour only.809

Magnesium sulfate
The role of magnesium sulfate is not established for children 5 years and younger, because there are few studies in this
age group. Nebulized isotonic magnesium sulfate may be considered as an adjuvant to standard treatment with
nebulized salbutamol and ipratropium in the first hour of treatment for children ≥2 years old with acute severe asthma

6. Diagnosis and management of asthma in children 5 years and younger 191

 (e.g. oxygen saturation <92%, Box 6-10, p.190), particularly those with symptoms lasting <6 hours.810 Intravenous
magnesium sulfate in a single dose of 40–50 mg/kg (maximum 2 g) by slow infusion (20–60 minutes) has also been
used.811

Assessment of response and additional bronchodilator treatment

Children with a severe asthma exacerbation must be observed for at least 1 hour after initiation of treatment, at which
time further treatment can be planned.
• If symptoms persist after initial bronchodilator: a further 2–6 puffs of salbutamol (depending on severity) may be
given 20 minutes after the first dose and repeated at 20-minute intervals for an hour. Consider adding 1–2 puffs of
ipratropium. Failure to respond at 1 hour, or earlier deterioration, should prompt urgent admission to hospital,
addition of nebulized ipratropium, and a short-course of oral corticosteroids (Evidence D).
• If symptoms have improved by 1 hour but recur within 3–4 hours: the child may be given more frequent doses of
bronchodilator (2–3 puffs each hour), and oral corticosteroids should be given. The child may need to remain in
the emergency department, or, if at home, should be observed by the family/carer and have ready access to

TE
emergency care. Children who fail to respond to 10 puffs of inhaled SABA within a 3–4 hour period should be

U
IB
referred immediately to hospital (Evidence D).

TR
• If symptoms resolve rapidly after initial bronchodilator and do not recur for 1–2 hours: no further treatment may be

IS
required. Further SABA may be given every 3–4 hours (up to a total of 10 puffs/24 hours) and, if symptoms persist

D
R
beyond 1 day, other treatments including inhaled and/or oral corticosteroids are indicated (Evidence D), as

O
outlined below.
PY
O
C
Box 6-12.Initial emergency department management of asthma exacerbations in children 5 years and younger
T
O
N

Therapy Dose and administration

O
-D

Supplemental oxygen Delivered by face nasal prongs or mask, as indicated to maintain oxygen saturation at 94–
L
IA

98%
ER
AT

Short-acting beta2- 2–6 puffs of salbutamol [albuterol] by spacer, or 2.5 mg by nebulizer, every 20 minutes for
M

agonist (SABA) first hour*, then reassess severity. If symptoms persist or recur, give an additional 2–3 puffs
D

per hour. Admit to hospital if >10 puffs required in 3–4 hours.

TE
H
IG

Systemic Give initial dose of oral prednisolone (1–2 mg/kg up to a maximum 20 mg for children
R

corticosteroids <2 years old; 30 mg for children 2–5 years)

PY
O

OR, intravenous methylprednisolone 1 mg/kg 6-hourly on day 1

C

Additional options in the first hour of treatment

Ipratropium bromide Consider adding 1–2 puffs of ipratropium bromide by pMDI and spacer
For children with moderate-severe exacerbations with a poor response to initial SABA,
give nebulized ipratropium bromide 250 mcg every 20 minutes for 1 hour only

Magnesium sulfate Consider nebulized isotonic magnesium sulfate (150 mg) 3 doses in the first hour of
treatment for children aged ≥2 years with severe exacerbation (Box 6-10, p.190)

See list of abbreviations (p.10). *If inhalation is not possible an intravenous bolus of terbutaline 2 mcg/kg may be given over 5 minutes, followed by
continuous infusion of 5 mcg/kg/hour812 (Evidence C). The child should be closely monitored, and the dose should be adjusted according to clinical
improvement and side-effects. See below for additional and ongoing treatment, including maintenance ICS. If a nebulizer is used, follow infection control
procedures.

192 6. Diagnosis and management of asthma in children 5 years and younger

Additional treatment
When treatment in addition to SABA is required for an exacerbation, the options available for children in this age group
include ICS; a short course of oral corticosteroid; and/or LTRA (see p.188). However, the clinical benefit of these
interventions – particularly on endpoints such as hospitalizations and longer-term outcomes – has not been impressive.
Maintain current controller treatment (if prescribed)
Children who have been prescribed maintenance therapy with ICS, LTRA or both should continue to take the prescribed
dose during and after an exacerbation (Evidence D).
Inhaled corticosteroids
For children not previously on ICS, an initial dose of ICS twice the low daily dose indicated in Box 6-7 (p.184) may be
given and continued for a few weeks or months (Evidence D). Some studies have used high-dose ICS (1600 mcg/day,
preferably divided into four doses over the day and given for 5–10 days) as this may reduce the need for
OCS.649,784,785,813,814 Addition of ICS to standard care (including OCS) does not reduce risk of hospitalization but reduces

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length of stay and acute asthma scores in children in the emergency department.815 However, the potential for side-

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effects with high-dose ICS should be taken into account, especially if used repeatedly, and the child should be

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monitored closely. For those children already on ICS, doubling the dose was not effective in a small study of mild-

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moderate exacerbations in children aged 6–14 years,816 nor was quintupling the dose in children aged 5–11 years with

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good adherence. This approach should be reserved mainly for individual cases, and should always involve regular

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follow-up and monitoring of adverse effects (Evidence D).
Oral corticosteroids
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For children with severe exacerbations, a dose of OCS equivalent to prednisolone 1–2 mg/kg/day, with a maximum of
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20 mg/day for children under 2 years of age and 30 mg/day for children aged 2–5 years, is currently recommended
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(Evidence A),817 although several studies have failed to show any benefits when given earlier (e.g. by parents or
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caregivers) during periods of worsening wheeze managed in an outpatient setting (Evidence D).801-804,818,819 A meta-
analysis demonstrated a reduced risk of hospitalization when oral corticosteroids were administered in the emergency
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department, but no clear benefit in risk of hospitalization when given in the outpatient setting.820 A course of 3–5 days is
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sufficient in most children of this age, and can be stopped without tapering (Evidence D), but the child must be reviewed
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after discharge (as below) to confirm they are recovering.

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In children discharged from the emergency department, an intramuscular corticosteroid may be an alternative to a
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course of OCS for preventing relapse,681 but the risk of long-term adverse effects must be considered. There is
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insufficient evidence to recommend intramuscular over oral corticosteroids.681

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Regardless of treatment, the severity of the child’s symptoms must be carefully monitored. The sooner therapy is started
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in relation to the onset of symptoms, the more likely it is that the impending exacerbation may be clinically attenuated or
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prevented.

Discharge and follow up after an exacerbation

Before discharge, the condition of the child should be stable (e.g., he/she should be out of bed and able to eat and
drink without problems).
Children who have recently had an asthma exacerbation are at risk of further exacerbations and require follow up. The
purpose is to ensure complete recovery, to establish the cause of the exacerbation, and, when necessary, to establish
appropriate maintenance treatment and adherence (Evidence D).

6. Diagnosis and management of asthma in children 5 years and younger 193

 Prior to discharge from the emergency department or hospital, family/carers should receive the following advice and
information (all are Evidence D).
• Instruction on recognition of signs of recurrence and worsening of asthma. The factors that precipitated the
exacerbation should be identified, and strategies for future avoidance of these factors implemented.
• A written, individualized action plan, including details of accessible emergency services
• Careful review of inhaler technique
• Further treatment advice explaining that:
o SABAs should be used on an as-needed basis, but the daily requirement should be recorded to ensure it is
being decreased over time to pre-exacerbation levels.
o ICS has been initiated where appropriate (at twice the low initial dose in Box 6-7 (p.184) for the first month
after discharge, then adjusted as needed) or continued, for those previously prescribed controller medication.
• A supply of SABA and, where applicable, the remainder of the course of oral corticosteroid, ICS or LTRA

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• A follow-up appointment within 1–2 days and another within 1–2 months, depending on the clinical, social and

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practical context of the exacerbation.

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194 6. Diagnosis and management of asthma in children 5 years and younger

 SECTION 2. CHILDREN 5 YEARS AND YOUNGER

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Chapter 7.

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Primary prevention
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of asthma in children
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KEY POINTS

• The development and persistence of asthma are driven by gene–environment interactions. For children, a ‘window
of opportunity’ to prevent asthma exists in utero and in early life, but intervention studies are limited.
• With regard to allergen avoidance strategies aimed at preventing asthma in children:
o Strategies directed at a single allergen have not been effective in reducing the incidence of asthma
o Multifaceted strategies may be effective, but the essential components have not been identified.
• Current recommendations for preventing asthma in children, based on high-quality evidence or consensus, include:
o Avoid exposure to environmental tobacco smoke during pregnancy and the first year of life.
o Encourage vaginal delivery.
o Where possible, avoid use of broad-spectrum antibiotics during the first year of life.
• Breast-feeding is advised, not for prevention of allergy and asthma, but for its other positive health benefits).

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FACTORS CONTRIBUTING TO THE DEVELOPMENT OF ASTHMA IN CHILDREN

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Asthma is a heterogeneous disease whose inception and persistence are driven by gene–environment interactions that

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are not yet fully understood. The most important of these interactions may occur in early life and even in utero. There is

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consensus that a ‘window of opportunity’ exists during pregnancy and early in life when environmental factors may

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influence asthma development. Multiple environmental factors, both biological and sociological, may be important in the

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development of asthma. Data from studies investigating the role of environmental risk factors for the development of
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asthma support further research on prevention strategies focusing on nutrition, allergens (both inhaled and ingested),
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pollutants (particularly environmental tobacco smoke), microbes, and psychosocial factors.

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‘Primary prevention’ refers to preventing the onset of disease. This chapter focuses on primary prevention in children.
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See p.116 and review articles49 for strategies for preventing occupational asthma.
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FACTORS ASSOCIATED WITH INCREASED OR DECREASED RISK OF ASTHMA IN CHILDREN

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Nutrition of mother and baby

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Maternal diet
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A large body of research investigating the development of allergy and asthma in children has focused on the mother’s
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diet during pregnancy. Current evidence does not clearly demonstrate that ingestion of any specific foods during
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pregnancy increases the risk for asthma. However, a study of a pre-birth cohort observed that maternal intake of foods
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commonly considered allergenic (peanut and milk) was associated with a decrease in allergy and asthma in the
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offspring.821 Similar data have been shown in a very large Danish National birth cohort, with an association between
ingestion of peanuts, tree nuts and/or fish during pregnancy and a decreased risk of asthma in the offspring.822,823
Epidemiological studies and randomized controlled trials on maternal dietary intake of fish or long-chain polyunsaturated
fatty acids during pregnancy showed no consistent effects on the risk of wheeze, asthma or atopy in the child.824-827
Dietary changes during pregnancy are therefore not recommended for prevention of allergies or asthma.
Maternal obesity and weight gain during pregnancy
Data suggest that maternal obesity and weight gain during pregnancy pose an increased risk for asthma in children. A
meta-analysis828 showed that maternal obesity in pregnancy was associated with higher odds of ever asthma or wheeze
or current asthma or wheeze; each 1 kg/m2 increase in maternal body-mass index (BMI) was associated with a 2% to
3% increase in the odd of childhood asthma. High gestational weight gain was associated with higher odds of ever
asthma or wheeze. However, no recommendations can be made at present, as unguided weight loss in pregnancy
should not be encouraged.

196 7. Primary prevention of asthma

Breastfeeding
Despite the existence of many studies reporting a beneficial effect of breastfeeding on asthma prevention, results are
conflicting,829 and caution should be taken in advising families that breastfeeding will prevent asthma.830 Breastfeeding
decreases wheezing episodes in early life; however, it may not prevent development of persistent asthma (Evidence D).
Regardless of any effect on development of asthma, breastfeeding should be encouraged for all of its other positive
benefits (Evidence A).
Timing of introduction of solids
Beginning in the 1990s, many national pediatric agencies and societies recommended delay of introduction of solid food,
especially for children at a high risk for developing allergy. However, meta-analyses have found no evidence that this
practice reduces the risk of allergic disease (including asthma).831 In the case of peanuts, early introduction may prevent
peanut allergy in high risk infants.831

Dietary supplements for mothers and/or babies

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Vitamin D

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Intake of vitamin D may be through diet, dietary supplementation or sunlight. A systematic review of cohort, case control

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and cross-sectional studies concluded that maternal dietary intake of vitamin D, and of vitamin E was associated with

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lower risk of wheezing illnesses in children.832 This was not confirmed in two randomized controlled trials (RCTs) of

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vitamin D supplementation in pregnancy, which compared standard-dose with high-dose vitamin D; however, a

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significant effect was not disproven.833,834 When the results from these two trials were combined, there was a 25%
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reduction of risk of asthma/recurrent wheeze at ages 0–3 years.835 The effect was greatest among women who
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maintained 25(OH)vitamin D levels of at least 30 ng/mL from the time of study entry through delivery, suggesting that
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sufficient levels of Vitamin D during early pregnancy may be important in decreasing risk for early life wheezing
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episodes,835 although in both trials, no effects of vitamin D supplementation on the development of asthma and recurrent
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wheeze were evident at the age of 6 years.836

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Fish oil and long-chain polyunsaturated fatty acids

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Systematic reviews of cohort studies about maternal dietary intake of fish or seafood during pregnancy824,837 and of
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RCTs on maternal dietary intake of fish or long-chained polyunsaturated fatty acids during pregnancy824 showed no
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consistent effects on the risk of wheeze, asthma or atopy in the child. One study demonstrated decreased
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wheeze/asthma in preschool children at high risk for asthma when mothers were given a high-dose fish oil supplement
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in the third trimester;838 however ‘fish oil’ is not well defined, and the optimal dosing regimen has not been established.
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Probiotics
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A meta-analysis provided insufficient evidence to recommend probiotics for the prevention of allergic disease (asthma,
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rhinitis, eczema or food allergy).839

Inhalant allergens
Sensitization to indoor, inhaled aeroallergens is generally more important than sensitization to outdoor allergens for the
presence of, and/or development of, asthma. While there appears to be a linear relationship between exposure and
sensitization to house dust mite,840,841 the relationship for animal allergen appears to be more complex.829 Some studies
have found that exposure to pet allergens is associated with increased risk of sensitization to these allergens,842,843 and
of asthma and wheezing.844,845 By contrast, other studies have demonstrated a decreased risk of developing allergy with
exposure to pets.846,847 Analyses of data from large populations of school-age children from birth cohorts in Europe have
found no association between pets in the homes early in life and higher or lower prevalence of asthma in children.848,849
For children at risk of asthma, dampness, visible mold and mold odor in the home environment are associated with
increased risk of developing asthma.850 Overall, there are insufficient data to recommend efforts to either reduce or
increase pre-natal or early-life exposure to common sensitizing allergens, including pets, for the prevention of allergies
and asthma.

7. Primary prevention of asthma 197

 Birth cohort studies provide some evidence for consideration. A meta-analysis found that studies of interventions
focused on reducing exposure to a single allergen did not significantly affect asthma development, but that multifaceted
interventions such as in the Isle of Wight study,851 the Canadian Asthma Primary Prevention Study,852 and the
Prevention of Asthma in Children study853 were associated with lower risk of asthma diagnosis in children younger than
5 years.854 Two multifaceted studies that followed children beyond 5 years of age demonstrated a significant protective
effect both before and after the age of 5 years.851,855 The Isle of Wight study has shown a continuing positive benefit for
early-life intervention through to 18 years of age;856 however, it remains unclear which components of the intervention
contributed to the effects reported, and the precise mechanism of these effects.
Treatment with grass pollen sublingual allergen immunotherapy (SLIT) for 3 years did not reduce the incidence of
asthma diagnosis (primary outcome) in a large randomized double-blind placebo-controlled trial in children aged 5–12
years with grass-allergic rhinoconjunctivitis, but asthma symptoms and asthma medication use were reduced. At
present, SLIT for children with grass allergic rhinoconjunctivitis is not recommended for asthma prevention.857 Additional
studies are needed.

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Pollutants

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Maternal smoking during pregnancy is the most direct route of pre-natal environmental tobacco smoke exposure.858 A

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meta-analysis concluded that prenatal smoking had its strongest effect on young children, whereas postnatal maternal

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smoking appeared only to affect asthma development in older children.859 Exposure to outdoor pollutants, such as living

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near a main road, is associated with increased risk of asthma.860,861 A 2019 study suggested that up to 4 million new

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pediatric asthma cases (13% of the global incidence) may be attributable to exposure to traffic-related air pollution.862
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Prenatal NO2, SO2, and PM10 exposures are associated with an increased risk of asthma in childhood,863 but it is
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difficult to separate effects of prenatal and postnatal exposure.
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Microbial effects
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The ‘hygiene hypothesis’, and the more recently coined ‘microflora hypothesis’ and ‘biodiversity hypothesis’,864 suggest
that human interaction with microbiota may be beneficial in preventing asthma. For example, there is a lower risk of
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asthma among children raised on farms with exposure to stables and consumption of raw farm milk than among children
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of non-farmers.865 The risk of asthma is also reduced in children whose bedrooms have high levels of bacterial-derived
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lipopolysaccharide endotoxin.866,867 Similarly, children in homes with ≥2 dogs or cats are less likely to be allergic than
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those in homes without dogs or cats.847 Exposure of an infant to the mother’s vaginal microflora through vaginal delivery
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may also be beneficial; the prevalence of asthma is higher in children born by cesarean section than those born
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vaginally.868,869 This may relate to differences in the infant gut microbiota according to their mode of delivery.870
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Respiratory syncytial virus infection is associated with subsequent recurrent wheeze, and preventative treatment of
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premature infants with monthly injections of the monoclonal antibody, palivizumab, (prescribed for prophylaxis of
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respiratory syncytial virus) is associated with a reduction in recurrent wheezing in the first year of life.871 However, a
sustained effect has not been definitively demonstrated. Although the risk of parent-reported asthma with infrequent
wheeze was reduced at 6 years, there was no impact on doctor-diagnosed asthma or lung function.872 Thus, the long-
term effect of palivizumab in the prevention of asthma remains uncertain.

Medications and other factors

Antibiotic use during pregnancy and in infants and toddlers has been associated with the development of asthma later in
life,873 although not all studies have shown this association.874 Intake of the analgesic, paracetamol (acetaminophen),
may be associated with an increased risk of asthma in both children and adults,875 although exposure during infancy
may be confounded by use of paracetamol for respiratory tract infections.875 Frequent use of paracetamol by pregnant
women has been associated with increased risk of asthma in their children.876
There is no evidence that vaccinations increase a child’s risk of developing asthma.

198 7. Primary prevention of asthma

Psychosocial factors
The social environment to which children are exposed may also contribute to the development and severity of asthma.
Maternal distress during pregnancy877 or during the child’s early years878 has been associated with an increased risk of
the child developing asthma.

Obesity
A meta-analysis of 18 studies found that being either overweight or obese was a risk factor for childhood asthma and
wheeze, particularly in girls.483 In adults, there is evidence suggesting that obesity affects the risk of asthma, but that
asthma does not affect the risk of obesity.879,880

ADVICE ABOUT PRIMARY PREVENTION OF ASTHMA

Based on the results of cohort and observational studies,881 and a GRADE-based analysis conducted for the Allergic
Rhinitis and its Impact on Asthma (ARIA) guidelines,829 parents/caregivers enquiring about how to reduce the risk of

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their children developing asthma can be provided with the advice summarized in Box 7-1.

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Possibly the most important factor is the need to provide a positive, supportive environment for discussion that

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decreases stress, and which encourages families to make choices with which they feel comfortable.

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Box 7-1. Advice about primary prevention of asthma in children 5 years and younger

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Parents/caregivers enquiring about how to reduce the risk of their child developing asthma can be provided with the
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following advice:
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• Children should not be exposed to environmental tobacco smoke during pregnancy or after birth.
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• Identification and correction of Vitamin D insufficiency in women with asthma who are pregnant, or planning
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pregnancy, may reduce the risk of early life wheezing episodes.

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• Vaginal delivery should be encouraged where possible.

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• The use of broad-spectrum antibiotics during the first year of life should be discouraged.
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Breastfeeding is advised, not for prevention of allergy or asthma, but for its other positive health benefits.
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7. Primary prevention of asthma 199

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 SECTION 3. TRANSLATION INTO CLINICAL
PRACTICE

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Chapter 8.

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Implementing asthma
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management strategies
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into health systems

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KEY POINTS

• In order to improve asthma care and patient outcomes, evidence-based recommendations must not only be
developed, but also disseminated and implemented at a national and local level, and integrated into clinical
practice.
• Recommendations for implementing asthma care strategies are based on many successful programs worldwide.
• Implementation requires an evidence-based strategy involving professional groups and stakeholders, and should
take into account local cultural and socioeconomic conditions.
• Cost-effectiveness of implementation programs should be assessed so a decision can be made to pursue or
modify them.
• Local adaptation and implementation of asthma care strategies is aided by the use of tools developed for this
purpose.

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INTRODUCTION

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Due to the exponential increase in medical research publications, practical syntheses are needed to guide policy makers

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and healthcare professionals in delivering evidence-based care. When asthma care is consistent with evidence-based

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recommendations, outcomes improve.188,882,883 This Strategy Report is a resource document for healthcare

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professionals, intended to set out the main goals of asthma treatment and the actions required to ensure their fulfilment,

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as well as to facilitate the achievement of standards for quality asthma care. These objectives can only be realized
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through local implementation in each country, region and healthcare organization.
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The use of rigorous methodologies such as GRADE1 for the development of clinical practice recommendations, and of
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ADAPTE884 and similar approaches for assisting the adaptation of recommendations for local country and regional
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conditions, has assisted in reducing biased opinion as the basis for asthma programs worldwide. Adaptation of clinical
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practice recommendations to local conditions using the GRADE method is costly, and often requires expertise that is not
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available locally; in addition, regular revision is required to remain abreast of developments, including drug availability
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and new evidence, and this is not easily achieved.885 Further, there is generally very limited high quality evidence
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addressing the many decision nodes in comprehensive clinical practice guidelines, particularly in developing countries.
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The GINA annual report is not a formal guideline but an evidence-based strategy, updated yearly from a review of the
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evidence published in the last 18 months. Each year’s report is an update on the entire strategy, so it does not use
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individual PICOT questions and GRADE, but the review process includes systematic reviews using these
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methodologies. (See section on methodology at www.ginasthma.org). As with other evidence-based clinical

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recommendations, the GINA strategy must be adapted to the local context for implementation in clinical practice.
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ADAPTING AND IMPLEMENTING ASTHMA CLINICAL PRACTICE GUIDELINES

Implementation of asthma management strategies may be carried out at a national, regional or local level.886 Ideally,
implementation should be a multidisciplinary effort involving many stakeholders, and using cost-effective methods of
knowledge translation.886-888 Each implementation initiative needs to consider the nature of the local health system and
its resources, including human resources, infrastructure, and available treatments (Box 8-1). Moreover, goals and
implementation strategies will need to vary from country to country and within countries, based on economics, culture
and the physical and social environment. Priority should be given to high-impact interventions.
Specific steps need to be followed before clinical practice recommendations can be embedded into local clinical practice
and become the standard of care, particularly in low resource settings. The individual steps are summarized in Box 8-2.

202 8. Implementing asthma management strategies in health systems

 Box 8-1. Approach to implementation of the Global Strategy for Asthma Management and Prevention

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Box 8-2. Essential elements required to implement a health-related strategy

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Steps in implementing an asthma strategy into a health system

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1. Develop a multidisciplinary working group.

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2. Assess the current status of asthma care delivery, outcomes e.g., exacerbations, admissions, deaths, care gaps
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and current needs.

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3. Select the material to be implemented, agree on main goals, identify key recommendations for diagnosis and
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treatment, and adapt them to the local context or environment.

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• In treatment recommendations, consider environmental issues (planetary health) in addition to patient health
4. Identify barriers to, and facilitators of, implementation.
5. Select an implementation framework and its component strategies.
6. Develop a step-by-step implementation plan:
• Select target populations and evaluable outcomes, and specify data coding requirements (if relevant).
• Identify local resources to support implementation.
• Set timelines.
• Distribute tasks to members.
• Evaluate outcomes.
7. Continually review progress and results to determine if the strategy requires modification.

8. Implementing asthma management strategies in health systems 203

BARRIERS AND FACILITATORS
Many barriers to, and facilitators of, implementation procedures have been described.888-891 Some of the barriers to
implementation of evidence-based asthma management relate to the delivery of care, while others occur at individual or
community level (see Box 8-3). Cultural and economic barriers can particularly affect the application of
recommendations.

Box 8-3. Examples of barriers to the implementation of evidence-based recommendations

Health care providers Patients

Insufficient knowledge of recommendations Low health literacy

Lack of agreement with recommendations or Insufficient understanding of asthma and its
expectation that they will be effective management

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Resistance to change Lack of agreement with recommendations

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External barriers (organizational, health policies, Cultural and economic barriers

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financial constraints)
Peer influence

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Lack of time and resources
Attitudes, beliefs, preferences, fears and

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Medico-legal issues misconceptions
Lack of accurate coding (diagnosis, exacerbations, ED PY
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and hospital admissions and deaths)
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See list of abbreviations (p.10).

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EXAMPLES OF HIGH IMPACT IMPLEMENTATION INTERVENTIONS

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Ideally, interventions should be applied at the level of both the patient and the health care provider and, where relevant,
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the health system. Studies of the most effective means of medical education show that it may be difficult to change
clinical practice. Examples of highly effective implementation interventions are shown in Box 8-4.
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Box 8-4. Examples of high-impact implementation interventions in asthma management

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• Free inhaled corticosteroids (ICS) for patients with a recent hospital admission and/or severe asthma892
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• Early treatment with ICS, guided self-management, reduction in exposure to tobacco smoke, improved access to
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asthma education188
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• Checklist memory aid for primary care, prompting assessment of asthma control and treatment strategies893
• Use of individualized written asthma action plans as part of self-management education476
• An evidence-based care process model for acute and chronic pediatric asthma management, implemented at
multiple hospitals894
See list of abbreviations (p.10).

204 8. Implementing asthma management strategies in health systems

EVALUATION OF THE IMPLEMENTATION PROCESS
An important part of the implementation process is to establish a means of evaluating the effectiveness of the program
and any improvements in quality of care. The Cochrane Effective Practice and Organisation of Care Group (EPOC)
offers suggestions on how to assess the effectiveness of interventions.895
Evaluation involves surveillance of traditional epidemiological parameters, such as morbidity and mortality, as well as
specific audits of both process and outcome within different sectors of the health care system. Each country should
determine its own minimum sets of data to audit health outcomes.

HOW CAN GINA HELP WITH IMPLEMENTATION?

The GINA Strategy Report provides an annually updated summary of evidence relevant to asthma diagnosis,
management and prevention that may be used in the formulation and adaptation of local guidelines; where evidence is
lacking, the report provides approaches for consideration. The GINA Dissemination Task Group assists in the
dissemination of the recommendations in the Strategy Report.

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A web-based implementation ‘toolkit’ will provide a template and guide to local adaptation and implementation of these

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recommendations, together with materials and advice from successful examples of asthma clinical practice guideline

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development and implementation in different settings.

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Educational materials and tools based on this Strategy Report are available from the GINA Website

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(www.ginasthma.org).

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GINA can be contacted via the website (www.ginasthma.org/contact-us).
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8. Implementing asthma management strategies in health systems 205

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12. Louis R, Satia I, Ojanguren I, et al. European Respiratory Society guidelines for the diagnosis of asthma in adults.
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13. Stanojevic S, Kaminsky DA, Miller MR, et al. ERS/ATS technical standard on interpretive strategies for routine
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14. Mortimer K, Lesosky M, García-Marcos L, et al. The burden of asthma, hay fever and eczema in adults in 17
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